polyvagal theory

How to Help Patients With Sexual Abuse

On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.

We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.

What is childhood sexual abuse?

“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”

The facts:

  • 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005)

  • 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994)

  • 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009)

How does it affect health?

Statistics show that 20-40% of survivors have no negative effects later in life. This is dependent on the response of caregivers. If someone was supported, protected, validated and responded to in a therapeutic way, the child has a higher chance of resiliency, which occurs through secure attachment. If the child has secure attachment, they can usually move forward with their lives.

What Simonton’s study shows is that women who were silenced, shamed or not given a voice to resolve those childhood sexual trauma issues have more mental and physical health issues than normal. If a woman was in a multi-dimensionally unstable family—drug use, no structural stability, alcoholism, revictimization—they are less likely to have resiliency.

Bodily representations of chronic stress:

Women who experienced childhood sexual abuse that was never recognized by a loving caregiver demonstrate biopsychosocial health problems both in childhood and later on in life. Sexual abuse causes intensive stress, and there are many subsequent health issues that stem from it.

What we see is the body begin to break down in the face of cortisol and other stress-related hormones that are released over years of unresolved trauma. One of the first indicators that drives them to seek medical help is usually a physical ailment. Often the patient experiences a few health issues, and ends up medicating the physical things, but the underlying cause is never treated.

These show up in many different ways, but there are some predominant issues such as:

  • Migraines

  • Bladder problems

  • Hypertension

  • Anxiety

  • PTSD

  • Depression

  • Chronic fatigue

  • TMJ

  • Irritable bowel

  • Fibromialgia

  • Non-epileptic seizures

  • Diabetes (chronic stress makes it more difficult to control)

If your patient does have a chronic illness, that does not mean they have experienced childhood sexual trauma. However, if they are retaining stress from childhood sexual abuse, they are more likely to develop comorbid mental and physical health issues later on.

Helping patients who have experienced sexual abuse

Because we are meaning-making creatures, we assign values to situations in our lives. If something good happens, we assign positive meanings to it—we are good people, we are highly valued, we are loved, etc. If something bad happens, we assign meaning to it—we are gross, we are worthless, we are disgusting. As we internalize these beliefs, we begin to act according to those meanings in ways that further damage our bodies and minds.

So how do we help our patients revisit the meaning they’ve assigned to these traumatic experiences? Simonton’s research shows different programs and therapies that can help patients cope with the trauma and relief their symptomology.

Ask them their story

It’s important for a patient to feel they are revealing their story slowly and gradually if that’s what makes them most comfortable. Simply asking for them to tell their story, then helping them unpack the information if they mention sexual abuse, is the best way to go about it.


Don’t lead the witness

Some therapists who have been sexually abused themselves, or who are particularly drawn to sexual abuse victims, can tend to transfer other patient’s experiences and make conclusions about patients who maybe have not experienced sexual abuse. If this is the case, the therapist can sometimes “lead the witness” by suggesting and leading the patient to believe they have experienced this when they have not.

Get the right team around them

It takes a good team to help someone recover from the trauma of sexual abuse. A good friend and family support group, plus therapists and internal medicine doctors (if the patient is on medications for their comorbid physical ailments) will all bolster the patient’s healing process. As a therapist, try to work with the patient’s internal medicine doctor to get a complete picture of the patient’s whole health. That way, as the patient heals, their medication can be managed accordingly.

Family involvement is critical to patients improving quality of life. Women who had a partner or sibling did much better and received the fullest benefit of having someone with them for home care and help. Also, someone with a spiritual base or community demonstrated higher health quality of life throughout intake and therapy.

Having someone with the patient who can be there day in and day out leads to a much higher success rate than when they have isolated experiences with the therapist. What is difficult is when a person experiences positive change in their therapy, but goes back to a rigid family who relates mostly to the patient’s illness. Illness can even create a continuing underlying family rule of keeping the victim in her lower, negatively associated role.

This also helps the women establish a new relationship with whoever they bring to therapy with them in a sexual abuse program—it helps them re-relate to a person in a new healthy way. They are no longer just the victim, they can portray new goals for healing and see rapid growth alongside their partner, family or sibling.

Get them back in touch with their bodies

Many people who experience sexual abuse learn that their body is their enemy, a conduit of pain. They learn to dissociate to be able to survive, and that ability carries over into adulthood. Dissociation is a powerful tool that helps them be able to mentally “leave” their body so they can withstand physical pain or trauma.

One fascinating note Simonton made is that patients never recounted physical pain when they talked about their trauma. Their minds were so disconnected from their bodies that they had no memory of the physical consequences. Women who do this have been carrying this unchartered territory of pain in their physical bodies for so long that by the time they reach adulthood, they have to learn to reconnect with their bodies.

When we start to break the meaning apart to help patients begin to heal, we have to very delicately focus on what it means to reconnect their mind and body.

Getting patients refocused on their bodies and unearthing the resident trauma that is causing the stress-related illnesses will help them unlock their emotional and mental healing processes. They have an opportunity to discover that their body has a story to tell. By reconnecting to their bodies, they give it a voice to process its trauma.

How to listen well

There are a few things you can do to make sure your patient feels heard and validated when they open up about their sexual abuse. “Witnessing” is an important one. Some people who’ve experienced sexual abuse have stories that were never heard or validated.

When someone shares a trauma story and it is not validated (shame and silencing might have occurred with their family) it can re-damage the patient. When they share and feel validated, it can be a healing experience for them.

Asking them how it makes their body feel when they share about their experience is also important. It connects the somatic representations with the emotions and thoughts, which is important because these patients have most likely dissociated from their emotions and bodily sensations in general, but more so when they talk about their experiences.

How to listen, empathize and not take on the emotional repercussions of trauma

Hearing stories of trauma is difficult as an empathic therapist.

  • Make sure you practice what you preach—have your own therapist to help when you need it.

  • Find a colleague who also helps people through childhood sexual abuse and go speak to them about your feelings.

  • Determine a way you can take care of yourself when you get home from your work day. Create a space where you can enjoy your family, spirituality and recreation (including cardio and strength training).

  • Develop a treatment team of colleagues that works together to process through the difficult stories you are each hearing.

  • Ask fellow therapists how they feel—check in with your coworkers and fellow therapists to make sure you are each sustaining your own health.

What therapy techniques work best for the sexually abused?

  • EFT - Emotionally focused therapy for couples is an effective, research based spousal support therapy system. This teaches the spouses to be effective witnesses in the trauma story and is able to bring the support to inside of their home.

  • DBT - Dialectical behavioral therapy is incredibly helpful for people who are struggling with PTSD related to childhood sexual abuse.

  • Transference Focused Psychotherapy

  • Mentalization Based Psychotherapy

How can you tell what patients should be in regular, weekly therapy versus an intensive outpatient therapy for sexual abuse?

Many excellent outpatient therapists are doing a great job at treating patients who have experienced childhood sexual abuse. There are a few specific factors that could mean your patient would be better treated in a more intensive outpatient programs, such as:

  • If they are in a multi dimensionally unstable family where their health is being impaired. (AKA If they do not have a support system at home.)

  • If they are medically fragile because the body is beginning to break down.

    • Some outpatient programs have internal medicine staff to ensure the patients who are medically fragile are being physically supported.

  • If your patient doesn’t seem to be thriving or processing well, recommend them to an intensive outpatient program, with the idea that when they become more stable, they will titrate down to weekly therapy again.

  • If the patient is on so many medications, recreational drugs or alcohol that it puts them in a dissociative state where they are unable to concentrate and do deeper therapy work, an outpatient program might help support them while they come off of medications and process the difficulty of their trauma. (Many therapists don’t realize how much medications can dull the mind and make therapy very difficult.)

    • After a few weeks, some patients may need to be detoxed before they can fully process the emotional trauma.

During supportive forms of therapy, who should the patient bring with them to be a support?

The family is not always the most supportive group for the patient. There could be a partner or friend who is therapeutic and non-judgemental enough. However, it’s important to encourage the patient to bring someone they feel completely safe around. This person is supposed to help the patient grow and move forward, to make good choices outside of the therapy office. This person must have the best interest of the patient in mind, and not prefer the old maladaptive patterns the patient was in. They must support the patient in their growth and journey of health.

Many patients end up in relationships that are similar to the dysfunction of their trauma. How do you encourage a patient to find or make a friend that is healthy and can support them?

  • Help the patient identify their feedback loops, through identifying their early narratives and early meaning-making experiences.

  • Start to make changes as to how the person sees themself so that they see themselves as worthy. This is the best way to have lasting effects on their relational patterns.

  • A victim is a victim because they have a perpetrator. If there is no longer a perpetrator because they’ve surrounded themselves with healthy people, the patient is able to shed the victim narrative.

From chronic pain to thriving

We have found that patients who receive therapy are able to reduce the negative biopsychosocial effects. They are getting back to school, getting new jobs or raises at work, setting new goals.

Some people get stuck and lose hope, they don’t see it’s possible. Eventually though, if they keep seeking help, they are able to have breakthroughs and change their lives.

If you’re interested in learning more, here are a few podcasts and articles about emotional trauma:

How to Treat Emotional Trauma

How to Fix Emotional Detachment

Emotional Shutdown - Understanding Polyvagal Theory

***If you have been sexually abused, or think you have been sexually abused, connect with a therapist who specializes in this.


Emotional Shutdown—Understanding Polyvagal Theory

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“Polyvagal Theory Simplified”

By David Puder, M.D.

Polyvagal theory explains three different parts of our nervous system and their responses to stressful situations. Once we understand those three parts, we can see why and how we react to high amounts of stress.

If polyvagal theory sounds as exciting as watching paint dry, stick around, trust me. It’s a fascinating explanation of how our body handles emotional stress, and how we can use different therapies it to rewrite the effect of trauma. 

Why is polyvagal theory important?

For therapists, and pop-psychology enthusiast alike, understanding polyvagal theory can help with:

  • Understanding trauma and PTSD

  • Understanding the dance of attack and withdrawal in relationships

  • Understanding how extreme stress leads to dissociation or shutting down

  • Understanding how to read body language

We like to think of our emotions as ethereal, complex, and difficult to categorize and identify.

The truth is that emotions are responses to a stimulus (internal or external). Often they happen out of our awareness, especially if we are out of touch, or incongruent, with our inner emotional life.

Our primal desire to stay alive is more important to our body than even our ability to think about staying alive. That’s where polyvagal theory comes in to play.

The nervous system is always running in the background, controlling our body functions so we can think about other things—like what kind of ice cream we’d like to order, or how to get that A in med school. The entire nervous system works in tandem with the brain, and can take over our emotional experience, even if we don’t want it to.

A story about a gazelle...

Animals are a great example of how we handle stress, because they react primally, without awareness. They do what we would, if we weren't so well tamed.

If you have ever watched a National Geographic Africa special, you’ve seen a lioness chase a gazelle. A group of gazelles is grazing, and suddenly one looks up, hyper aware of what is happening around him. The whole group notices and pays attention.

After a moment, the lioness starts her chase. The gazelle she’s singled out runs as fast as he can (sympathetic nervous system), until he is caught. When he is caught, he instantly goes limp (parasympathetic nervous system).

The lioness drags the gazelle back to her cubs, where they begin to play with it before they go in for the kill. If the lioness gets distracted, and the gazelle sees a moment of opportunity, he’s up and sprinting off again, looking like he suddenly came back to life (back into sympathetic nervous system response).

When the gazelle was caught, with fangs around his neck, his shutdown response kicked in—he froze. When he saw the opportunity to run, his fight or flight kicked in, and he ran.

Poyvagal theory covers those three states—connection, fight or flight, or shutdown. 

Here's how they work...

Connection Mode

or...rest and relaxation...or myelinated vagus nerve of the parasympathetic nervous system coming from the nucleus ambiguus response

During non-stressful situations, if we are emotionally healthy, our bodies stay in a social engagement state, or a happy, normal, non-freak-out state.

I like to call it “connection.” By connection, I mean that we are capable of a “connected” interaction with another human being. We are walking around, unafraid, enjoying our day, eating with friends and family and our body and emotions feel normal.  

It’s also called ventral vagal response, because that’s the part of the brain that is activated during connection mode. It’s like a green light for normal life.

How does this look and feel?

  • Our immune system is healthy.

  • We feel normal happiness, openness, peace, and curiosity about life.

  • We are sleeping well and eating normally.

  • Our face is expressive.

  • We emotionally relate to others.

  • We more easily understand and listen to others.

  • Our body feels calm and grounded.

 

Freeze, Flight, Fight, or Puff Up

...or the sympathetic nervous system response

The sympathetic nervous system is our immediate reaction to stress that affects nearly every organ in the body.

The sympathetic nervous system causes that “fight or flight” state we have all heard of. It gives us those cues so that it can keep us alive.

How does this happen? How does this look and feel?

  • We sense a threat and freeze to scan the surroundings for real danger.

  • We release cortisol, epinephrine and norepinephrine to help us accomplish what we need to—get away, or fight our enemy.

  • Our heartbeat spikes, we sweat, and we feel more mobilized.

  • We feel anxious, afraid, or angry.

  • There may be flashes of facial expressions of fear and anger, with the background of more of a still face.  If positive emotions are present, they usually look forced.

  • Our digestion slows down as blood rushes to the muscles.

  • Our blood vessels constrict to the intestines and dilate to the muscles needed to run or fight.

  • We may want to run away, or punch someone, or react physically in some way, or just puff-up and look scary.

  • Our muscles may feel tense, electric, tight, vibrating, aching, trembling, and hard.

  • Our hands may be clammy.  

  • Our stomach may be painfully knotted.

  • All our senses focus.   

  • Our gestures may show guarding of our vital organs, fists clenched, or puffing ourselves up to look bigger or stronger.

In fight or flight, at some level we believe we can still survive whatever threat we think is dangerous.

Shut Down

...or the Unmyelinated Vagus of the Parasympathetic Nervous System coming from the Dorsal Motor Nucleus

What’s interesting about this part of the parasympathetic nervous system? Its function is to keep us frozen as an adaptive mechanism to help us survive to either fight or flight again.

When David Livingston was attacked by a lion, he later reported, “it caused a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening.”

When our sympathetic nervous system has kicked into overdrive, and we still can’t escape and feel impending death the dorsal vagal parasympathetic nervous system takes control.

It causes freezing or shutdown, as a form self preservation. (Think of someone who passes out under extreme stress.)

How does this look and feel?

  • Emotionally, it feels like dissociation, numbness, dizzy, hopelessness, shame, a sense of feeling trapped, out of body, disconnected from the world

  • Our eyes may look fixed and spaced out

  • The dorsal motor nucleus through the unmyelinated vagus nerve decreases our heart rate, blood pressure, facial expressions, sexual and immune response systems

  • We may be triggered to feel nauseated, throw up, defecate, spontaneously urinate

  • We may feel low or no pain

  • Our lungs (bronchi) constrict and we breathe slower

  • We may have difficulty getting words out or feel constriction around our throat

  • Our brain has decreased metabolism and this causes a loss of body awareness, limp limbs, decreased ability to think clearly, and decreased ability to lay down narrative memories

  • Our body posture may collapse or curl up in a ball

In shutdown mode, at some level our nervous system believes we are in a life-threatening situation, and it tries to keep us alive through keeping our body still.

Some people who have had both attachment trauma and subsequent trauma can have chronic suicidality, and dissociation episodes that last days to months. Research shows that long term solutions include:

  • Dialectical behavioral therapy

  • Mentalization based therapy

  • Transference focused therapy

How trauma affects the nervous system

As humans, we do the same thing as that gazelle when we perceive emotional or physical danger. We alternate between peaceful grazing (parasympathetic - connection mode), fight or flight (sympathetic system- fight and flight) or shutdown (parasympathetic- shut down mode).

Our response is all in our perception of the event. Maybe someone was just playing a game when they jumped out to scare us, but we fainted. Whatever the reason, whether the incident was intentional or not, our body shifted into shutdown mode, we registered it as a trauma. our body shifted into shutdown mode.

Or maybe the trauma event was really, life threatening, and our nervous system responded appropriately to the stimuli.

No matter what the cause was, our brain believed what was happening was life threatening enough that it caused our body to go into flight, flight, or shutdown mode.

If someone has been through such a traumatic event that their body tips into shutdown response, any event that reminds the person of that life-threatening occurrence can trigger them into disconnection or dissociation again.

People can even live in a state of disconnection or shutdown for days or months at a time.

Veterans often experience this during loud, sudden noises such as fireworks or thunderstorms. A woman who was raped might quickly switch into hypervigilant or dissociated response if she feels someone is following her. Someone who was abused might be triggered when even another person starts yelling.

The problem occurs when we haven’t processed the original trauma in such a way that the original trauma is resolved.

That’s what PTSD (post-traumatic stress disorder) is—our body’s overreaction to a small response, and either stuck in fight and flight or shut down. 

People who experience trauma and the shutdown response usually feel shame around their inability to act, when their body did not move. They often wish they would have fought more during those moments.  

A Vietnam vet may feel they failed their companions who died around them while they stood, frozen in fear. A rape victim may feel he or she didn’t fight off their rapist because they froze. A victim of abuse may feel they quit trying to escape their abuser, and that they are weak or failed.

Much of “stress” training, which trains people to continue to remain in fight and flight mode, aims to keep people out of dissociation during real life or death situations. Unfortunately, these practices aren’t common beyond elite sports teams or special forces.  The right amount of stress, with good recovery, can lead our nervous systems into higher levels of adaptation.  

Coming out of shutdown mode

So how do we climb back out of shutdown mode?

The opposite of the dorsal vagal system is the social engagement system.

So, in short, what fixes shutdown mode is bringing someone into healthy social engagement, or proper attachment.

Getting down into the nuts and bolts of how this works in our body can help us understand why we feel the way we do physically when your body is in fight, flight, or shut down mode.

When we understand why our body reacts the way it does, like a string of clues and some basic science about the brain, we can understand how to switch states. We can begin to move out of the fight or flight state, out of the shutdown mode, and back into the social engagement state.

As therapists, whether we are just establishing a connection with a new, anxious patient, or helping them deal with their deepest traumatic memories, knowing how to navigate the polyvagal states is important.

It can also be helpful if you have just identified yourself in some of these symptoms. Such as, “When I’m with my parents, even as an adult, and they start fighting, I feel lightheaded and disconnected.”

If you’ve seen some of these things in yourself, hopefully through therapy, and even understanding how this works, you can pull yourself out of a disconnected state.

Studies show that some parts of the brain shut down during the recall of traumatic events, including the verbal centers and the reasoning centers of the brain (Van Der Kolk, 2006).

This is why it’s important to conduct therapy, or coming out of shutdown mode, in a safe, healthy way, in a safe, healthy environment. This is why positive attachment is imperative. Otherwise, you run the risk of retraumatizing the patient.

Because I am a psychiatrist, I am going to write this to demonstrate how to help a patient switch out of shutdown mode.

However, these tips still apply to those who are just understanding how shutdown mode works. And it can even help those who feel shut down to begin to know how to try and attain a healthy social engagement mode again.

  • Have a trust-based relationship. Because of the potential to re-traumatize, don’t even address intensely traumatic events—especially ones where you think shutdown mode kicked in, until the therapeutic relationship feels deeply connected.

    It’s important as the therapist to allow the patient to express things they couldn’t express to other people—shameful feelings, anger, sexual response, anything that feels frightening to share with others.

  • Find your own calm center. If you can empathize with their distress, stay in the moment with them, and help them feel connected during their shutdown, you are throwing them a lifeline. You’re helping them come out of shutdown, into social engagement.

    It’s important to fight against the urge to dissociate, no matter how gruesome the subject matter is. As therapists, we could dissociate because of the mirror neuron response—to mirror our patient’s brain, and because when hearing horrific trauma, it’s easy to imagine it happening to us.

    The human experience is so powerful that when we re-engage the trauma, with someone else to support us, it rewrites that event in our brain, adding in the feeling of being supported within the trauma memory. We create new neural pathways around the trauma, and we can change our body’s response to it.
     

  • Let the patient lead. Don’t go on a witch hunt. If the patient brings it up, lean into the subject. But it is harmful to prompt the patient into something that isn’t there by asking leading questions and trying to get them to confess. Don’t let your own experience lead you to imagine they have also experienced something.  

  • Normalize their response. The entire polyvagal theory should make us say “thank you!” to our bodies. Even if that systems is overactive at times—unwarranted panic or anxiety—that our body is watching out for us, trying to keep us alive.

    Our body reacting in that way is the same thing as the gazelle either running away or going limp. And gazelles have no idea what emotions are in the first place.

    Now that the patient understands that their emotional response was adaptive, primal, and appropriate, we can get rid of the shame that their non-reaction caused.

  • Help them find their anger. Anger is an incredibly adaptive emotion, and it’s one we don’t allow ourselves to have. We think anger is bad. But really, anger shows us where our healthy boundaries were crossed.

    Anger gives us energy to overcome the obstacle. We can help the patient see they had the emotional energy to overcome, but the energy wasn’t able to be manifested at the time they wanted it.

    If, in a session, we can get a patient to identify their anger, they will see that they were not completely unresponsive to the traumatic event. If we can help them feel even the tiniest movement of a microexpression of anger on their face—the slight downturn of the inner eyebrows—we can show them their body didn’t totally betray them in that moment.

    We can reconnect their body and their feelings to their emotions. This helps develop a state of congruence—where their inside feelings match their outer demonstrations of those feelings.

Further, as a dissociative memory is explored, finding anger and reducing shame allows for the memory to fundamentally change. Anger brings them out of dissociation, even if it is anger at you, the therapist!
 

  • Introduce body movement. Because shutdown causes us to freeze, reactivating body movements while talking about the trauma is a great way to reconnect the body and mind, to bring them out of shutdown.

    For example, one of my patients was in an accident. When the EMS showed up, they strapped her to a gurney to load her into the back of an ambulance. More than the actual accident, being trapped on that gurney was traumatic for her. For the entire ride to the hospital, she was terrified that she’d hurt her neck, and all of the anxiety that surrounds a neck injury caused her to be frozen in fear.

    Even in talking about the trauma in the therapy session, her body was stiff, frozen, and she was dissociating.

    I asked her, “In what way would you have wanted to move during that moment?” She said she would have wanted her arms to be able to move. I asked her to slowly, mindfully, move her arms in the way she would have wanted to.

    It’s important to do the movement mindfully and slowly, focusing on the sensation of the movement. That patient felt a huge release of energy. In the following sessions, she was able to tell the memory as a narrative, instead of dissociating.

    Having the patient move—slow punching, kicking, twisting, running slowly in place—flips the person from shutdown into the fight or flight mode, with the goal being to move into connection, or social engagement, mode.

    Body movement exercises, in conjunction with talking to a therapist, can fundamentally change the memory.
     

  • Practicing assertiveness. Emotional shutdown can occur within relationships where one person feels they cannot communicate with the other person well.

    One therapist, John Gottman, describes this practice as stonewalling. Practicing assertiveness can help the patient feel more in control of their emotional state, and feel safe to move into healthy relationship patterns.

  • Breath work, mindfulness, and yoga all have a role in becoming more connected to your here and now body. I will discuss this subject at length in a future podcast.  
     

  • Become a Judo Master and practice strength training. Teaching yourself how to better protect yourself in the future can be powerful and also resets the stress system over time. I talked about strength training in a prior episode, and in the future will talk about learning to fight as an active way to not remain passive or a victim both in mindset and capability.  Further doing something hard, on an ongoing basis, allows for building inner strength which can keep you in fight and flight longer before going into shut down.

Next Steps:

Listen to these episodes next:

How to Fix Emotional Detachment

Meaning and Viktor Frankl’s Logotherapy

How Empathy Works and How To Improve It

Join the community on social media:

Instagram: @Dr.DavidPuder

Twitter: @DavidPuder 

Facebook: @DrDavidPuder

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