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Co-Occurring Mental Illness and Substance Abuse 

3/8/2013

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Dual diagnosis services are treatments for people who suffer from co-occurring disorders -- mental illness and substance abuse. Research has strongly indicated that to recover fully, a consumer with co-occurring disorder needs treatment for both problems -- focusing on one does not ensure the other will go away. Dual diagnosis services integrate assistance for each condition, helping people recover from both in one setting, at the same time.

Dual diagnosis services include different types of assistance that go beyond standard therapy or medication: assertive outreach, job and housing assistance, family counseling, even money and relationship management. The personalized treatment is viewed as long-term and can be begun at whatever stage of recovery the consumer is in. Positivity, hope and optimism are at the foundation of integrated treatment. 

 What are the consequences of co-occurring severe mental illness and substance abuse?
For the consumer, the consequences are numerous and harsh. Persons with a co-occurring disorder have a statistically greater propensity for violence, medication noncompliance, and failure to respond to treatment than consumers with just substance abuse or a mental illness. These problems also extend out to these consumers’ families, friends and co-workers.

Having a simultaneous mental illness and a substance abuse disorder frequently leads to overall poorer functioning and a greater chance of relapse. These consumers are in and out of hospitals and treatment programswithout lasting success. People with dual diagnoses also tend to have tardive dyskinesia (TD) and physical illnesses more often than those with a single disorder, and they experience more episodes of psychosis. In addition, physicians often don’t recognize the presence of substance abuse disorders and mental disorders, especially in older adults.

Socially, people with mental illnesses often are susceptible to co-occurring disorders due to "downward drift." In other words, as a consequence of their mental illness they may find themselves living in marginal neighborhoods where drug use prevails. Having great difficulty developing social relationships, some people find themselves more easily accepted by groups whose social activity is based on drug use. Some may believe that an identity based on drug addiction is more acceptable than one based on mental illness.

Consumers with co-occurring disorders are also much more likely to be homeless or jailed. An estimated 50 percent of homeless adults with serious mental illnesses have a co-occurring substance abuse disorder.  Meanwhile, 16% of jail and prison inmates are estimated to have severe mental and substance abuse disorders. Among detainees with mental disorders, 72 percent also have a co-occurring substance abuse disorder.

Consequences for society directly stem from the above. Just the back-and-forth treatment alone currently given to non-violent persons with dual diagnosis is costly. Moreover, violent or criminal consumers, no matter how unfairly afflicted, are dangerous and also costly. Those with co-occurring disorders are at high risk to contract AIDS, a disease that can affect society at large. Costs rise even higher when these persons, as those with co-occurring disorders have been shown to do, recycle through healthcare and criminal justice systems again and again. Without the establishment of more integrated treatment programs, the cycle will continue.

Why is an integrated approach to treating severe mental illnesses and substance abuse problems so important?
Despite much research that supports its success; integrated treatment is still not made widely available to consumers. Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions. Mental health services tend not to be well prepared to deal with  patients having both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.

Providing appropriate, integrated services for these consumers will not only allow for their recovery and improved overall health, but can ameliorate the effects their disorders have on their family, friends and society at large. By helping these consumers stay in treatment, find housing and jobs, and develop better social skills and judgment, we can potentially begin to substantially diminish some of the most sinister and costly societal problems: crime, HIV/AIDS, domestic violence and more.

There is much evidence that integrated treatment can be effective. For example:
        ·  Individuals with a substance abuse disorder are more likely to receive treatment if they have a co-occurring mental disorder. 
        ·  Research shows that when consumers with dual diagnosis successfully overcome alcohol abuse, their response to treatment improves remarkably. 
 
With continued education on co-occurring disorders, hopefully, more treatments and better understanding are on the way.

 What does effective integrated treatment entail?
 Effective integrated treatment consists of the same health professionals, working in one setting, providing appropriate treatment for both mental health and substance abuse in a coordinated fashion. The caregivers see to it that interventions are bundled together; the consumers, therefore, receive consistent treatment, with no division between mental health and substance abuse assistance. The approach, philosophy and recommendations are seamless, and the need to consult with separate teams and programs is eliminated.
 
Integrated treatment also requires the recognition that substance abuse counseling and raditional mental health counseling are different approaches that must be reconciled to treat co-occurring disorders. It is not enough merely to teach relationship skills to a person with bipolar disorder. They must also learn to explore how to avoid the relationships that are intertwined with their substance abuse.

 Providers should recognize that denial is an inherent part of the problem. Patients often do not have insight as to the seriousness and scope of the problem. Abstinence may be a goal of the program but should not be a precondition for entering treatment. If dually diagnosed clients do not fit into local Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups, special peer groups based on AA principles might be developed.

Clients with a dual diagnosis have to proceed at their own pace in treatment. An illness model of the problem should be used rather than a moralistic one. Providers need to convey understanding of how hard it is to end an addiction problem and give credit for any accomplishments. Attention should  be given to social networks that can serve as important rein forcers. Clients should be given opportunities to socialize, have access to recreational activities, and develop peer relationships. Their families should be offered support and education, while learning not to react with guilt or blame but to learn to cope with two interacting illnesses.

 What are the key factors in effective integrated treatment?
 There are a number of key factors in an integrated treatment program.

Treatment must be approached in stages. First, a trust is established between the consumer and the caregiver. This helps motivate the consumer to learn the skills for actively controlling their illnesses and focus on goals. This helps keep the consumer on track, preventing relapse. Treatment can begin at any one of these stages; the program is tailored to the individual.

Assertive outreach has been shown to engage and retain clients at a high rate, while those that fail to include outreach lose clients. Therefore, effective programs, through intensive case management, meeting at the consumer’s residence, and other methods of developing a dependable relationship with the client, ensure that more consumers are consistently monitored and counseled.

Effective treatment includes motivational interventions,which, through education, support and counseling, help empower deeply demoralized clients to recognize the importance of their goals and illness self-management.

 Of course, counseling is a fundamental component of dual diagnosis services. Counseling helps develop positive coping patterns, as well as promotes cognitive and behavioral skills. Counseling can be in the form of individual, group, or family therapy or a combination of these.

A consumer’s social support is critical. Their immediate environment has a direct impact on their choices and moods; therefore consumers need help strengthening positive relationships and jettisoning those that encourage negative behavior.


Effective integrated treatment programs view recovery as a long-term, community-based process, one that can take months or, more likely, years to undergo. Improvement is slow even with a consistent treatment program. However, such an approach prevents relapses and enhances a consumer’s gains.

To be effective, a dual diagnosis program must be comprehensive, taking into account a number of life’s aspects: stress management, social networks, jobs, housing and activities. These programs view substance abuse as intertwined with mental illness, not a separate issue, and therefore provide solutions to both illnesses together at the same time.

Finally, effective integrated treatment programs must contain elements of cultural sensitivity and competence to even lure consumers, much less retain them. Various groups such as African-Americans, homeless, women with children, Hispanics and others can benefit from services tailored to their particular racial and cultural needs.




Resources: NAMI


 
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Mental Illness 101 Part II

2/20/2013

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Mental Illness and the Brain
The term mental illness clearly indicates that there is a problem with the mind. But is it just the mind in an abstract sense, or is there a physical basis to mental illness?  As scientists continue to investigate mental illnesses and their causes, they learn more and more about how the biological processes that make the brain work are changed when a person has a mental illness. 

Before thinking about the problems that occur in the brain when someone has a mental illness, it is helpful to think about how the brain functions normally. The brain is an incredibly complex organ.  It makes up only 2 percent of our body weight, but it consumes 20 percent of the oxygen we breathe and 20 percent of the energy we take in.  It controls virtually everything we as humans experience, including movement,
sensing our environment, regulating our involuntary body processes such as  breathing, and controlling our emotions. Hundreds of thousands of chemical reactions occur every second in the brain; those reactions underlie the thoughts, actions, and behaviors with which we respond to environmental stimuli.  In short, the brain dictates the internal processes and behaviors that allow us to survive. 

How does the brain take in all this information, process it, and cause a response?  The basic functional unit of the brain is the neuron.  A neuron is a specialized cell that can
produce different actions because of its precise connections with other neurons, sensory receptors, and muscle cells.

The nervous system uses a variety of neurotransmitter molecules, but each neuron specializes in the synthesis and secretion of a single type of neurotransmitter.  Some of the predominant neurotransmitters in the brain include glutamate, GABA, serotonin,
dopamine, and norepinephrine. Each of these neurotransmitters has a specific distribution and function in the brain.

Mental health professionals base their diagnosis and treatment of mental illness on the symptoms that a person exhibits. The goal for these professionals in treating a patient is to relieve the symptoms that are interfering with the person’s life so that the person can function well.  Research scientists, on the other hand, have a different goal.  They want to learn about the chemical or structural changes that occur in the brain when someone has a mental illness.  If scientists can determine what happens in the brain, they can use that knowledge to develop better treatments or find a cure. 

The techniques that scientists use to investigate the brain depend on the questions they are asking. For some questions, scientists use molecular or biochemical methods to investigate specific genes or proteins in the neurons.  For other questions, scientists want to visualize changes in the brain so that they can learn more about how the activity or structure of the brain changes.  Historically, scientists could examine brains only after death, but new imaging procedures enable scientists to study the brain in living animals, including humans. It is important to realize that these brain imaging techniques are not used for diagnosing mental illness. Mental illnesses are diagnosed by the set of symptoms that an individual exhibits. The imaging techniques would not enable the mental health professional to diagnose or treat the patient more effectively. 
Some of the techniques are also invasive and expose patients to small amounts of radiation.  Research studies using these tests are generally not conducted with children or adolescents. 

One extensively used technique to study brain activity and how mental illness changes the brain is positron emission tomography (PET).  PET scans can answer a variety of
questions about brain function, including where the neurons are most active.  Scientists can use PET to measure changes in the activity of specific brain areas in a person who has a mental illness. Scientists can also investigate how the mentally ill brain changes after a person receives treatment.

PET imaging is not the only technique that researchers use to investigate how mental illness changes the brain.  Different techniques provide different information to scientists.   Another important technique is magnetic resonance imaging (MRI). 
Unlike PET, which reveals changes in activity level, MRI is used to look at structural changes in the brain.  For example, MRI studies reveal that the ventricles, or spaces within the brain, are larger in individuals who have schizophrenia compared with those of healthy individuals.

Other techniques that scientists use to investigate function in the living brain include single photon emission computed tomography (SPECT),functional magnetic resonance imaging (fMRI), and electroencephalography (EEG).  Each technique has its own
advantages, and each provides different information about brain structure and function.  Scientists often use more than one technique when conducting their research.

 Causes of Mental Illness 
At this time, scientists do not have a complete understanding of what causes mental illnesses. If you think about the structural and organizational complexity of the brain
together with the complexity of effects that mental illnesses have on thoughts, feelings, and behaviors, it is hardly surprising that figuring out the causes of mental illnesses is a daunting task.  The fields of neuroscience, psychiatry, and psychology address different aspects of the relationship between the biology of the brain and individuals’
behaviors, thoughts, and feelings, and how their actions sometimes get out of control. Through this multidisciplinary research, scientists are trying to find the causes of mental illnesses. Once scientists can determine the causes of a mental illness, they can use that knowledge to develop new treatments or to find a cure. 

Most scientists believe that mental illnesses result from problems with the communication between neurons in the brain (neurotransmission).  For example,
the level of the neurotransmitter serotonin is lower in individuals who have depression. This finding led to the development of certain medications for the illness.  Selective serotonin reuptake inhibitors (SSRIs) work by reducing the amount of serotonin that is taken back into the presynaptic neuron.   This leads to an increase in the amount of serotonin available in the synaptic space for binding to the receptor on the postsynaptic neuron.  Changes in other neurotransmitters (inaddition to serotonin) may occur in depression, thus adding to the complexity of the cause underlying the disease. 

Scientists believe that there may be disruptions in the neurotransmitters dopamine, glutamate, and norepinephrine in individuals who have schizophrenia. One  indication that dopamine might be an important neurotransmitter in schizophrenia comes from the observation that cocaine addicts sometimes show symptoms similar to schizophrenia.  Cocaine acts on dopamine-containing neurons in the brain to increase the amount of dopamine in the synapse. 

Risk Factors for Mental Illness
Although scientists at this time do not know the causes of mental illnesses, they have identified factors that put individuals at risk.  Some of these factors are environmental, some are genetic, and some are social.  In fact, all these factors most likely combine to influence whether someone becomes mentally ill.  Genetic, environmental, and social factors interact to influence whether someone becomes mentally ill.  
 
Environmental factors such as head injury, poor nutrition, and exposure to toxins (including lead and tobacco smoke) can increase the likelihood of developing a mental illness.

Genes also play a role in determining whether someone develops a mental illness. The illnesses that are most likely to have a genetic component include autism, bipolar disorder, schizophrenia, and ADHD.  For example, the observation that children with ADHD are much more likely to have a sibling or parent with ADHD supports a role for genetics in determining whether someone is at risk for ADHD.  In studies of twins, ADHD is significantly more likely to be present in an identical twin than a fraternal
twin. The same can be said for schizophrenia and depression. Mental illnesses are not triggered by a change in a single gene; scientists believe that the interaction of several genes may trigger mental illness.  Furthermore, the combination of genetic, environmental, and social factors might determine whether a case of mental illness is mild or severe.  
 
Social factors also present risks and can harm an individual’s, especially a child’s, mental health. Social factors include:
     •Severe parental discord,
     •Death of a family member or close friend,
     •Parent’s mental illness,
     •Parent’s criminality
     •Overcrowding,
     •Economic hardship,
     •Abuse,
     •Neglect, and
     •Exposure to violence.

 Treating Mental Illness
 At this time, most mental illnesses cannot be cured, but they can usually be treated effectively to minimize the symptoms and allow the individual to function in work, school, or social environments.  To begin treatment, an individual needs to see a qualified mental health professional. The first thing that the doctor or other mental health professional will do is speak with the individual to find out more about his or her symptoms, how long the symptoms have lasted, and how the person’s life is being affected.  The physician will also do a physical examination to determine whether
there are other health problems.  For example, some symptoms (such as emotional swings) can be caused by neurological or hormonal problems associated with chronic illnesses such as heart disease, or they can be a side effect of certain medications. 
After the individual’s overall health is evaluated and the condition diagnosed, the doctor and/or health practitioner will develop a treatment plan. Treatment can involve both medications and psychotherapy, depending on the disease and its severity.

Medications
Medications are often used to treat mental illnesses. Through television commercials and magazine advertisements, we are becoming more aware of those medications. To become fully effective, medications for treating mental illness must be taken for a few days or a few weeks. When a patient begins taking medication, it is important for a doctor to monitor the patient’s health. If the medication causes undesirable side effects, the doctor may change the dose or switch to a different medication that produces fewer side effects. If the medication does not relieve the symptoms, the doctor may prescribe a different medication. 

Sometimes, individuals who have a mental illness do not want to take their medications because of the side effects. It is important to remember that all medications have both positive and negative effects. For example, antibiotics have revolutionized treatment for some bacterial diseases. However, antibiotics often affect beneficial bacteria in the human body, leading to side effects such as nausea and diarrhea. Psychiatric drugs, like other medications, can alleviate symptoms of mental illness but can also produce unwanted side effects.  People, who take a medication to treat an illness, whether it is a mental illness or another disease, should work with their doctors to understand what medication they are taking, why they are taking it, how to take it, and what side effects to watch for.

Occasionally, the media reports stories in which the side effects of a psychiatric medication are tied to a potentially serious consequence, such as suicide. In these cases, it is usually very difficult to determine how much suicidal behavior was due to the mental disorder and what the role of the medication might have been. Medications for treating mental illness can, like other medications, have side effects. The psychiatrist or physician can usually adjust the dose or change the medication to alleviate side effects.

 Psychotherapy
Psychotherapy is a treatment method in which a mental health professional (psychiatrist, psychologist, social worker or other mental health professional) and the patient discuss problems and feelings. This discussion helps patients understand the basis of their problems and find solutions. Psychotherapy may take different forms. The therapy can help patients:
     •Change thought or behavior patterns,
     •Understand how past experiences influence current behaviors,
     •Solve other problems in specific ways, or
     •Learn illness self-management skills. 
 
Psychotherapy may occur between a therapist and an individual; a therapist and an individual and his or her family members; or a therapist and a group.  Often, treatment for mental illness is most successful when psychotherapy is used in combination with
medications.  For severe mental illnesses, medication relieves the symptoms and psychotherapy helps individuals cope with their illness.

Just as there are no medications that can instantly cure mental  illnesses, psychotherapy is not a one-time event. The amount of time a person spends in psychotherapy can range from a few visits to a few years, depending on the nature of the illness or problem and the treatment model used.   


 
 
Resources: NIH

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Mental Illness 101- Part I

2/19/2013

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Mental Illness-What Is It?
A mental illness can be defined as a health condition that changes a person’s thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning.  As with many diseases, mental illness is severe in some cases and mild in others. Individuals who have a mental illness don’t necessarily look like they are sick, especially if their  illness is mild. Other individuals may show more explicit symptoms such as confusion, agitation, or withdrawal.  There are many different mental illnesses, including depression, schizophrenia, attention deficit hyperactivity disorder (ADHD), autism, and obsessive-compulsive disorder, PTSD and others.  Each illness alters a person’s thoughts, feelings, and/or behaviors in distinct ways.

 Not all brain diseases are categorized as mental illnesses.  Disorders such as epilepsy, Parkinson’s disease, and multiple sclerosis are brain disorders, but they are considered neurological diseases rather than mental illnesses.  Interestingly, the lines between mental illnesses and these other brain or neurological disorders is blurring somewhat.  As scientists continue to investigate the brains of people who have mental illnesses, they are learning that menta illness is associated with changes in the brain’s structure, chemistry, and function and that mental illness does indeed have a biological basis.  This ongoing research is, in some ways, causing scientists to minimize the distinctions between mental illnesses and these other brain disorders.

 Many people feel that mental illness is rare, something that only happens to people with life situations very different from their own, and that it will never affect them.  Studies of the epidemiology of mental illness indicate that this belief is far from accurate. In fact, the surgeon general reports that
mental illnesses are so common that few U.S. families are untouched by them. 
 

Mental Illness- Who Has It?
Even if you or a family member has not experienced mental illness directly, it is very likely that you have known someone who has.  Estimates are that at least one in four people is affected by mental illness either directly or indirectly. Consider the following statistics to get an idea of just how widespread the effects of mental illness are in society: 
          •According to recent estimates, approximately 20 percent of Americans, or about one in five people over the age of 18, suffer from a diagnosable mental disorder in a given year.
         •Four of the 10 leading causes of disability—major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder—are mental illnesses.
         •About 3 percent of the population has more than one mental illness at a time.
         •About 5 percent of adults are affected so seriously by mental illness that it interferes with their ability to function in society.  
         •Approximately 20 percent of doctors’ appointments are related to anxiety disorders such as panic attacks.
         •Eight million people have depression each year.
         •Two million Americans have schizophrenia disorders, and 300,000 new cases are diagnosed each year.

Mental illness is not uncommon among children and adolescents.  Approximately 12 million children under the age of 18 have mental disorders.  The National Mental Health Association has compiled some statistics about mental illness in children and adolescents:
         •Mental health problems affect one in every five young people at any given time.
         •An estimated two-thirds of all young people with mental health problems are not receiving the help they need.
         •Less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services.
         •As many as 1 in every 33 children may be depressed. Depression in adolescents may be as high as 1 in 8.
         •Suicide is the third leading cause of death for 15- to 24-years-olds and the sixth leading cause of death for 5- to 15-year-olds.            
         •Between 118,700 and 186,600 youths in the juvenile justice system have at least one mental illness.
         •Of the 100,000 teenagers in juvenile detention, an estimated 60 percent have behavioral, cognitive, or emotional problems.
         ·Schizophrenia is rare in children under age 12, but it occurs in about 3 of every 1,000 adolescents.

Each mental illness has its own characteristic symptoms.  However, there are some general warning signs that might alert you that someone needs professional help.  Some of these signs include:
         •Marked personality change,
         •Inability to cope with problems and daily activities,
         •Strange or grandiose ideas,
         •Excessive anxieties,
         •Prolonged depression and apathy,
         •Marked changes in eating or sleeping patterns,
         •Thinking or talking about suicide or harming oneself,
         •Extreme mood swings—high or low,
         •Abuse of alcohol or drugs, and
         •Excessive anger, hostility, or violent behavior.

A person who shows any of these signs should seek help from a qualified health professional.

Mental Illness Diagnosis
To be diagnosed with a mental illness, a person must be evaluated by a qualified professional who has expertise in mental health.  Mental health professionals include psychiatrists, psychologists, psychiatric nurses, social workers, and mental health counselors.  Family doctors, internists, and pediatricians are usually qualified to diagnose common mental disorders such as depression, anxiety disorders, and ADHD.  In many cases, depending on the individual and his or her symptoms, a mental health professional who is not a psychiatrist will refer the patient to a
psychiatrist. A psychiatrist is a medical doctor (M.D.) who has received additional training in the field of mental health and mental illnesses. Psychiatrists evaluate the person’s mental condition in coordination with his or her physical condition and can prescribe medication.  Only psychiatrists and other M.D.s can prescribe medications to treat mental illness.

Unlike some disease diagnoses, doctors can’t do a blood test or culture some microorganisms to determine whether a person has a mental illness.  Maybe scientists will develop discrete physiological tests for mental illnesses in the future; until then, however, mental health professionals will have to diagnose mental illnesses based on the symptoms that a person has. Basing a diagnosis on symptoms and not on a quantitative medical test, such as a blood chemistry test, a throat swab, X-rays, or urinalysis, is not unusual.  Physicians diagnose many diseases, including migraines, Alzheimer’s disease, and Parkinson’s disease based on their symptoms alone.  For other diseases, such as asthma or mononucleosis, doctors rely on analyzing symptoms to get a good idea of what the problem is and then use a physiological test to provide additional information or to confirm their diagnosis. 

When a mental health professional works with a person who might have a mental illness, he or she will, along with the individual, determine what symptoms the individual has, how long the symptoms have persisted, and how his or her life is being affected.  Mental health professionals often gather information through an interview during which they ask the patient about his or her symptoms, the length of time that the symptoms have occurred, and the severity of the symptoms.  In many cases, the professional will also get information about the patient from family members to obtain a more comprehensive picture.  A physician likely will conduct a physical exam and consult the patient’s history to rule out other health problems. 

Mental health professionals evaluate symptoms to make a diagnosis of mental illness.  They  rely on the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; currently, the fourth edition), published by the American Psychiatric Association, to diagnose a specific mental illness.   For each mental illness, the DSM-IV gives a general description of the disorder and a list of typical symptoms.  Mental health professionals refer to the DSM-IV to confirm that the symptoms a patient exhibits match those of a specific mental illness.   Although the DSM-IV provides valuable information that helps mental health professionals diagnose mental illness, these professionals realize that it is important to observe patients over a period of time to understand the individual’s mental illness and its effects on his or her life.

In Mental Illness 101-Part II, we will look further into mental illness and look at risk factors for having mental illness.      


 
Resources: NIH

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    I am a Licensed Clinical Social Worker with a strong spiritual foundation providing counseling in the Tallahassee, Florida area.  My areas of interest include grief and loss, depression and anxiety, women's emotional health, trauma related issues such as PTSD, family substance abuse issues, domestic violence and family counseling including couples counseling, children and adolescent behavioral issues and parenting. Giving back is very rewarding with the growth and satisfaction of each client. It is my passion and my honor to serve others. 
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