Substance Use Disorders (SUD)

Emotional breakthrough and psychedelics: validation of the emotional breakthrough inventory

The authors validate a six‑item Emotional Breakthrough Inventory (Cronbach’s α=0.932), demonstrating that emotional breakthrough is a distinct, dose‑dependent component of the acute psychedelic experience that is more likely with therapeutic planning and intent. In a low‑well‑being subsample (n=75) emotional breakthrough and mystical-type experiences independently predicted subsequent increases in well‑being, whereas challenging experiences predicted smaller improvements.

Authors

  • Robin Carhart-Harris
  • Leor Roseman
  • Mendel Kaelen

Published

Journal of Psychopharmacology
individual Study

Abstract

Background

Psychedelic therapy is gaining recognition and the nature of the psychedelic experience itself has been found to mediate subsequent long-term psychological changes. Much emphasis has been placed on the occurrence of mystical-type experiences in determining long-term responses to psychedelics yet here we demonstrate the importance of another component, namely: emotional breakthrough.

Methods

Three hundred and seventy-nine participants completed online surveys before and after a planned psychedelic experience. Items pertaining to emotional breakthrough were completed one day after the psychedelic experience, as were items comprising the already validated Mystical Experience Questionnaire and the Challenging Experience Questionnaire. Emotional breakthrough, Mystical Experience Questionnaire and Challenging Experience Questionnaire scores were used to predict changes in well-being (Warwick-Edinburgh Mental Wellbeing Scale) in a subsample of 75 participants with low well-being baseline scores (⩽45).

Results

Factor analyses revealed six emotional breakthrough items with high internal consistency (Cronbach’s alpha=0.932) and supported our prior hypothesis that emotional breakthrough is a distinct component of the psychedelic experience. Emotional breakthrough scores behaved dose-dependently, and were higher if the psychedelic was taken with therapeutic planning and intent. Emotional breakthrough, Mystical Experience Questionnaire and Challenging Experience Questionnaire scores combined, significantly predicted subsequent changes in well-being ( r=0.45, p=0.0005, n=75), with each scale contributing significant predictive value. Emotional breakthrough and Mystical Experience Questionnaire scores predicted increases in well-being and Challenging Experience Questionnaire scores predicted less increases.

Conclusions

Here we validate a six-item ‘Emotional Breakthrough Inventory’. Emotional breakthrough is an important and distinct component of the acute psychedelic experience that appears to be a key mediator of subsequent longer-term psychological changes. Implications for psychedelic therapy are discussed.

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Research Summary of 'Emotional breakthrough and psychedelics: validation of the emotional breakthrough inventory'

Editorial

βBlossom's Take

This is useful because it gives a specific, measurable counterpart to the better-known mystical-experience literature. The six-item Emotional Breakthrough Inventory helps separate cathartic resolution from more global altered-state intensity, and the finding that emotional breakthrough and mystical-type experience each predict later well-being keeps the focus on which parts of the session may matter.

Introduction

Psychedelic therapy is regaining attention as a treatment paradigm in mental health, and previous work has shown that qualities of the acute psychedelic experience help to determine longer-term psychological outcomes. Much prior research has emphasised mystical-type or "peak" experiences (commonly measured with the Mystical Experience Questionnaire, MEQ) and challenging experiences (measured with the Challenging Experience Questionnaire, CEQ) as important state predictors. The authors argue that these instruments do not clearly capture a related but distinct phenomenon: the overcoming or resolution of difficult emotions or memories during a psychedelic experience, which they term emotional breakthrough (EB). They note conceptual overlap between EB and historical notions of catharsis, and suggest EB may act as a positive predictor of subsequent mental-health improvements whereas CEQ scores have sometimes predicted worse outcomes. Roseman and colleagues set out to develop and validate a brief Emotional Breakthrough Inventory (EBI). The study aimed to assess the EBI's internal consistency, factor structure, discriminant validity versus the MEQ and CEQ, dose- and context-dependence, and its ability to predict changes in psychological well-being. The investigators tested five explicit hypotheses concerning dose-dependence, influence of therapeutic intention/setting, discriminability from existing scales, and predictive power for changes in well-being, both alone and combined with MEQ and CEQ measures. The work was conducted as a prospective, naturalistic online survey of self-selected psychedelic users rather than a controlled laboratory trial.

Methods

The study was a prospective, observational online survey advertised via social media and hosted at psychedelicsurvey.com. Ethical approval and written informed consent were obtained. Baseline data were collected one week before participants' planned psychedelic experience and included demographics, intentions for the session and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), which served as the primary dependent variable. Retrospective reports of the acute psychedelic experience were collected one day after use and comprised the newly developed EBI, the MEQ and the CEQ, plus self-reported drug type and an estimated dose expressed in LSD-equivalent categories. Long-term outcomes (WEMWBS) were collected two weeks after the experience. Most analyses used data from 379 participants; prediction of change in well-being focused on a subsample of 75 participants with relatively low baseline WEMWBS scores (⩽45) to reduce floor/ceiling issues. EBI item construction began with eight candidate items derived from prior trial interview content and clinical observation; two items were negatively keyed. Items were rated on a 0–100 visual analogue scale. Five experts reviewed the items for face validity. Other instruments used were the 30-item MEQ and the 26-item CEQ (scored 0–100 after rescaling), and the 14-item WEMWBS (scored over two weeks). Drug-type options included psilocybin, LSD, ayahuasca, DMT variants, salvia, mescaline, ibogaine and free-text responses. Dosing was categorised into five LSD-equivalent bands from low to extremely high. Participants also reported whether the setting was designed with a therapeutic objective and rated therapeutic intention and willingness to confront difficult emotions. Statistical analysis used SPSS 25 and Matlab 2017. Exploratory factor analysis via principal component analysis (PCA) determined the EBI factor structure and informed item retention. Internal consistency was assessed with Cronbach's alpha (a measure of how closely related items are within a scale). Discriminant validity was tested by entering all 62 items from the EBI, MEQ and CEQ into a single PCA to evaluate whether EB emerged as a distinct factor. Predictive validity was evaluated with Pearson correlations and multiple regression analyses predicting ΔWEMWBS (two-week change score), with the EBI, MEQ and CEQ entered as independent variables. An initial prediction analysis used the targeted low-well-being subsample (n=75) and a secondary exploratory regression used a larger sample with available follow-up WEMWBS (n=253). Collinearity diagnostics (tolerance values) were reported for regression predictors.

Results

Exploratory factor analysis of the eight initial EBI items (n=379) supported a two-factor solution. The Kaiser-Meyer-Olkin measure was 0.877 and Bartlett's test was significant, indicating suitability for PCA. Factor 1 comprised six positively keyed items and explained 57.1% of the variance; Factor 2 contained the two negatively keyed items and explained 18.3%. The two negative items were therefore discarded and the six-item EBI used in subsequent analyses. Internal consistency for the six-item EBI was very high (Cronbach's alpha=0.932). The average of the six items correlated strongly with the factor score (r=0.996, p<0.0001) and was used as the total EBI score. Mean scores were reported as: EBI 43±31.5, MEQ 57±22.63, and CEQ 19.7±16.4. EBI scores showed expected dose- and context-dependence. Estimated drug dose correlated positively with EBI (Spearman r s =0.192, p=0.0001, n=379). Baseline therapeutic intention and willingness to confront difficult emotions correlated with higher EBI scores (r s =0.256 and r s =0.279, respectively, p<0.0001, n=351). Participants who reported their setting was designed with a therapeutic objective had higher EBI scores (47.9±30.1, n=144) than those who did not (31.6±29.1, n=168); this difference was highly significant (p<0.0001) with a medium effect size (Cohen's d=0.55). Discriminant validity testing used PCA on all 62 items from EBI, MEQ and CEQ (KMO=0.941, Bartlett's test significant). A three-factor solution emerged: a first factor loaded heavily on MEQ items (with some EBI loading), a second factor loaded on CEQ items, and a third factor loaded on EBI items alone. The first three components explained 31.3%, 15.4% and 6.1% of the variance, respectively. Correlation analysis showed the EBI correlated strongly with MEQ dimensions and with the grief subscale of the CEQ, but MEQ subscales correlated more strongly with each other than with EBI, supporting discriminability. Predictive validity analyses focused on the low-baseline well-being subsample (n=75). For these participants, WEMWBS increased from 38.8±5.3 at baseline to 47.9±7.2 at two weeks (paired t-test significant). EBI scores correlated with change in well-being (ΔWEMWBS) at r=0.294, p=0.005 (one-tailed). A multiple regression with ΔWEMWBS as the dependent variable and EBI, MEQ and CEQ as predictors produced a significant model (r=0.45, p=0.0005, one-tailed). Standardised beta coefficients were all significant and in the predicted directions: βEBI=0.29, p=0.017; βMEQ=0.24, p=0.038; βCEQ=-0.35, p=0.002 (one-tailed). Collinearity tolerances were acceptable (0.631, 0.634, 0.814), indicating the predictors provided relatively independent information. An exploratory regression in a larger sample with two-week WEMWBS available (n=253) yielded a marginally significant overall model (r=0.153, p=0.059, one-tailed). In this group WEMWBS increased from 49.5±8.6 at baseline to 52.7±7.3 at two weeks. In the larger sample the standardised betas were smaller and marginal: βEBI=0.115, p=0.063; βMEQ=0.075, p=0.15; βCEQ=-0.086, p=0.01 (one-tailed). The authors attribute the reduced effect size in the larger sample to a ceiling effect at baseline WEMWBS. Overall, the combined model of EBI, MEQ and CEQ accounted for close to 20% of variance in well-being change in the targeted low-baseline sample.

Discussion

Roseman and colleagues interpret their findings as supporting the EBI as a reliable, concise measure of a distinct component of the acute psychedelic experience that they label emotional breakthrough. The six-item EBI demonstrated strong internal consistency, dose- and context-dependence, and discriminant validity versus established measures of mystical-type and challenging experiences. Consistent with the authors' hypotheses, higher EBI scores were associated with greater increases in psychological well-being two weeks after a psychedelic experience, and a model combining EBI, MEQ and CEQ performed better at predicting well-being change than any single instrument alone. The combined model explained nearly 20% of variance in the targeted low-baseline subsample, which the authors consider notable given the non-clinical, largely well sample and the uncontrolled naturalistic design. The investigators emphasise the importance of context: therapeutic intention and a therapeutic setting were associated with stronger EB, reinforcing prior suggestions that contextual factors (for example music, empathic support and therapeutic alliance) are key mediators of psychedelic-assisted interventions. They situate EB alongside other candidate state and contextual predictors such as psychological insight and integration, and argue for broader measurement of these constructs in future work. The discussion also notes the potential neurobiological relevance of state measures, briefly referencing prior findings that brain entropy increases during psychedelics correlate with later psychological change. Three limitations highlighted by the authors are the sample composition (mostly healthy, experienced psychedelic users, limiting clinical generalisability), reliance on self-reported drug identity and dose in uncontrolled settings, and limited convergent-validity analyses owing to lack of existing measures closely aligned to EB. The authors recommend applying the EBI in clinical trials and controlled settings, comparing it with qualitative interview outcomes, and examining other dependent variables beyond general well-being (for example disorder-specific symptom change). They conclude that EB is an important component of psychedelic-assisted therapy that should be routinely measured alongside peak and challenging experiences to better quantify psychological mechanisms that accompany pharmacological effects.

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METHODS

The study was approved by Imperial College Research Ethics Committee and the Joint Research Compliance Office at Imperial College London and carried out in accordance with principles of good clinical practice. Written informed consent was obtained from all subjects. The original survey has now closed but revised and still active versions of related surveys can be found here at www.psychedelicsurvey.com.

CONCLUSION

Here we sought to devise and carry out validation work on a new scale intended to describe an important and hitherto under-quantified component of the psychedelic experience, the EB. We anticipate that this scale will serve as a useful 'state' predictor of the longer-term psychological outcomes after a psychedelic experience -supplementing already existing state predictor measures such as the MEQ and CEQ. We call this new scale the 'EBI'. Results revealed that (as measured by the EBI) emotional breakthrough is dose dependent and sufficiently different from the mystical-type and challenging experience as indexed by the MEQ and CEQ respectively. Consistent with a major prior hypothesis, we found that (like the MEQ) the EBI significantly predicts post-psychedelic changes in well-being (greater EB, greater increases in well-being) and we also discovered that the EBI does not render either the CEQ or MEQ redundant but rather a multi-factorial predictor model that combines all three measures performs better than any alternative that neglects any one of them. The combined EBI, MEQ and CEQ model is able to predict close to 20% of the variance in well-being changes after a psychedelic experience, a not inconsiderable amount given the relatively 'well' nature of this sample and uncontrolled study design. We also found that both therapeutic intention and therapeutic setting can predict the intensity of EB, suggesting that, as with other components of the acute psychedelic experience, EB is highly influenced by the context in which the psychedelic is taken. Taken together, these results support the addition of the EBI to the arsenal of tools used to quantitatively describe the psychedelic experience and predict its longer-term psychological effects. Modern phenomenological analysesand therapists' accountshave tended to recognise the importance of EB within the context of psychedelic experiences and psychedelic therapy; however, a validated quantitative measure of this phenomenon is arguably overdue and there is a significant contemporary need for it. Perhaps due to the relative dearth of psychedelic research since the 1960s and a particular bias common among those few research teams working within the current resurgent era, contemporary researchers have tended to place significant emphasis on the mystical-type experience, in part due to well-replicated findings that its occurrence is predictive of relevant psychological outcomes, such as improvements in well-beingchanges in personality, and improvements in clinical outcomes in patient populations. The present work has demonstrated the added value of measuring EB for predicting subsequent psychological outcomes after a psychedelic experience. However, are there other 'state' and perhaps 'contextual' factors that are also important determinants of longer-term responses to psychedelics -and might there be alternative dependent variables that are differentially influenced by state and contextual predictors? Indeed, these variables may also interact in non-linear ways. We have previously emphasised, and sought to measure and demonstrate, the influence of contextual factors such as the presence of others, associated therapeutic alliance, a therapeutic intention and setting and a willingness to surrender or 'let-go' to the psychedelic experience on longer-term psychological outcomes, and found them to be important. Like 'state' predictors of long-term responses, it is logical to see these factors as mediators of the relevant changes, as they are temporal antecedents of them. Other factors we predict may be important for influencing long-term changes include psychological insight and psychological integration. Insight is a phenomenon that may occur acutely in a state-like fashion (like EB) but could only be more protracted, crystallising in the days to weeks following a psychedelic experience. Integration is another protracted phenomenon that may have no clear end-point as such. Much more work is needed to understand the neurobiology of the entire psychedelic psychotherapy process and this will naturally require brain imaging at various time points: before, during and after a specific psychedelic experience. Further discussion of this topic is beyond the remit of the present article, only to say that there is some evidence that the magnitude of increased brain entropy, a known biomarker of the psychedelic state, has been found to be predictive of subsequent psychological changes (increased trait 'openness') over a consistent time-scale as was measured here in relation to well-being. Finally, we advocate looking at other dependent variables than just well-being. Well-being is a useful index of mental health in general populationsbut it may be that certain psychiatric disorders and/or symptom clusters behave differently in their relation to predictor variables. This is something we intend to investigate more fully in future analyses plus new and on-going studies. Our novel analysis is part of an effort to elucidate the importance of the psychological mechanism of psychedelics alongside their pharmacological uses, and by doing so to emphasise the importance of the context in which these drugs are taken. That is to say that affirming that the experience mediates the clinical outcomes, means that the regular clinical context will have to be modified to accommodate psychedelics as an effective psychopharmacological intervention within psychiatry. On that note, there is a lesson from history we would like to bring to readers' attention before closing: psychedelic therapy was once a relatively widely practised intervention in Western psychiatry before opinion shifted against it. As the pharmacological revolution in psychiatry gathered momentum in the 1960s and the thalidomide scandal occurred at a related time, regulations on experimental medicines tightened, as did the methods for assessing their safety and efficacy. Within this climate, some efforts were made to extricate the basic pharmacological action of LSD from the psychotherapeutic manner in which it was typically administered, e.g. by giving the drug in a psychologically 'sterile' environment. In at least one published study, patients treated with LSD were placed in a belt that restrained them to their bed. Unsurprisingly, such efforts to 'neutralise' context (which is, of course, a misnomer) tended to reveal that LSD without contextual support does not nearly have the same therapeutic value and safety profile as LSD given with therapeutic support. These results, combined with the spread of unfounded but nonetheless affecting misinformation about LSDplus a tightening of legislation on drugs of potential misuse, best exemplified by the 1970 Controlled Substances Act (1970), signalled the demise of psychedelic psychotherapy. The present study's analyses confirm the findings of other analysesthat context is an essential component of the psychedelic modeland that if one wishes to promote a positive therapeutic response to a psychedelic, then heeding and optimising the role of certain contextual components is entirely necessary, whereas neglecting them is bad practice if not unethical. Our hope is that psychedelic therapy of the future can be done in a way and a context that encourages and allows the free release of emotion, e.g. using tools such as music, empathic listening and purposefully designed supportive environments, even if this presents a significant challenge to the conventions of mainstream medicine: [Practicing psychedelic therapy here] has transformed the entire hospital, because the whole atmosphere engendered by LSD has spread throughout the hospital and, in fact, forms an essential part of the hospital culture. If LSD is given in a large institutional setting, treatment will be ineffective unless this transformation has occurred.cited inThree limitations of the present study should be noted. First, the present study's population contained mostly healthy experienced psychedelic users, and therefore the results do not necessarily apply to clinical population. In these users the outcomes in well-being might be related to the expectation build around psychedelic use in the psychedelic culture and literature. Furthermore the pharmacological mechanism of psychedelics might be different in these users due to greater exposure to this class of drugs. To improve translational relevance, future studies should use the EBI in clinical populations to assess its ability to predict changes in clinically recognised phenomena, such as depressive symptoms and anxiety. The prediction model of changes in well-being predicted only 20% of the variance. However, we do expect this model to perform better in a clinical trial and in a controlled environment. Second, the study has relied on self-reports of drugs, doses and timing, which are not as accurate as in laboratory studies. Psychedelics that are sold in the market are unreliable in many cases and one cannot be sure which drug and what dose was used. Third, there was limited analysis of convergent validity. Although there is clearly some overlap with the MEQ, we are not aware of any other questionnaires that measure a construct closely related to EBI. One way to address this in the future might be to compare EBI scores with quantitative outcomes from qualitative interviews, to assess whether there is some correspondence. A better demonstration of the convergent validity of the EBI will serve to further strengthen its construct validity. In conclusion, EB is an essential component of psychedelicassisted therapy, and therefore should be measured in future experimental medicine studies and clinical trials with psychedelics, alongside measures of peak and challenging experiences. Quantifying the psychological mechanism of psychedelicassisted therapy is essential as psychedelic-assisted therapy is rightly both a pharmacological and psychological intervention. The predictive value of peak experiences is well-established within this context, and now the importance of EBs can be better researched and potentially supported as well. Furthermore, based on qualitative studiesand a broader awareness of the phenomenology of the psychedelic experience, we believe there is scope for additional quantitative measures (e.g. of psychological insight) to be developed, so that a fuller understanding of the psychological and neurobiological mechanism of psychedelic (mind-revealing) therapy can be appreciated and utilised for positive ends.

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14 cited
Perceived attachment history predicts psychedelic experiences: A naturalistic study

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7 cited
Effects of discontinuation of serotonergic antidepressants prior to psilocybin therapy versus escitalopram for major depression

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25 cited
Unique Psychological Mechanisms Underlying Psilocybin Therapy Versus Escitalopram Treatment in the Treatment of Major Depressive Disorder

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25 cited
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31 cited
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35 cited
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44 cited
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31 cited
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21 cited
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21 cited
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19 cited
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38 cited
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100 cited
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30 cited
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54 cited
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179 cited
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35 cited
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46 cited
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8 cited
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38 cited
15 cited
Subtypes of the psychedelic experience have reproducible and predictable effects on depression and anxiety symptoms

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23 cited
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22 cited
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27 cited
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19 cited
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54 cited
9 cited
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167 cited
155 cited
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73 cited
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208 cited
Pattern Breaking: A Complex Systems Approach to Psychedelic Medicine

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287 cited
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425 cited
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222 cited
20 cited
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104 cited
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134 cited
46 cited
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37 cited
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16 cited
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37 cited
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50 cited
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94 cited
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11 cited
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3 cited
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37 cited
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32 cited
Trial of Psilocybin versus Escitalopram for Depression

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65 cited
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79 cited
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60 cited
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224 cited
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165 cited
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66 cited
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128 cited
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145 cited
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546 cited
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106 cited
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50 cited
102 cited
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253 cited
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257 cited
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184 cited
348 cited