Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT)
Teaching and Learning: Cognitive Processing Therapy (CPT) Versus Virtual Reality Therapy (VRT) for veterans with Post Traumatic Stress Disorder (PTSD)
The quest for knowledge is a process that involves both teaching and learning. The two words, even though closely related, have different meanings. While teaching refers to the process of delivering a lecture or a lesson to a group of people (students), learning is an individual’s initiative to gain the knowledge through studies, observation, and experience or through being taught (Westerdahl et al., 2020).
Teaching therefore is not the only means through which students can learn as implied by the preceding statement. Further, the teacher’s level of expertise and life experience determines the outcomes of teaching. For example, as a veteran who was once diagnosed with a chronic post-traumatic stress disorder (PTSD) and underwent virtual reality therapy (VRT) and cognitive processing therapy (CPT), I believe that the experience and the skills I gained through the entire process are adequate to help me deliver a lesson on a similar subject to different groups.
I will leverage active learning strategies during the 45-60 minutes teaching. Active learning, as Harris and Bacon (2019 Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT)) contend, is superior to the passive learning as it allows the students to participate more, and it also provides immediate feedback.
Besides gaining the knowledge, the graduate level students will also be able to sharpen their critical thinking skills through active learning strategies. This is achieved through the exercises and assignments that enable them to think critically. Moreover, assuming that majority of the graduate level students are adults, this paper also includes a discussion on the elements of andragogy that I will incorporate into the proposed teaching demonstration.
Definition and Diagnosis of PTSD
Exposures to stressful or traumatic life events predispose individuals to a wide spectrum of psychiatric conditions. PTSD, according to the latest classification by the American Psychiatric Association (2013), is categorized under trauma and stressor-related disorders. The Diagnostic Statistical Manual of Mental Disorders-5 defines PTSD as a syndromal disorder that results from exposure to catastrophic and stressful life events (American Psychiatric Association, 2013).
Examples of the stressful life events include but are not limited to war (combat), serious accidents, death and rape or sexual assault (Mann & Marwaha, 2020). Due to the constant intrusive symptoms, and the significant cognitive and functional impairment related to PTSD, it is essential to adequately diagnose at early stages and design appropriate interventions to mitigate the long-term adverse outcomes.
The DSM-5 provides diagnostic criteria for PTSD. The following diagnostic criteria (A-H) are applicable for adults, adolescents and children above 6-years of age. Criteria A: Exposure to sexual violence, serious accident, threatened or real death by experiencing the traumatic event directly, witnessing the event, learning of the event occurrence to a close friend or a family member or through being repeatedly exposed to the aversive details of the catastrophic events.
Criteria B: presence of intrusive symptoms such as recurrent distressing memories about the events, recurrent nightmares or distressing dreams and flashbacks about the occurrences and pervasive psychological distress. Criteria C: avoidance of events, people or situations that cause memories about the traumatic events. Criteria D: partial amnesia, pervasive negative emotional state, anhedonia and feelings of detachment from friends or close family.
Criteria E: hyper-arousal state including easy irritability, recklessness, hypervigilance and difficulty in concentrating. Criteria F: the symptoms must have occurred for duration more than 1-month. Criteria G: the disturbance causes significant functional impairment (social or occupational) and criteria H state that the symptoms are not attributed to alcohol, drugs or a medical condition (American Psychiatric Association, 2013).
According Mann and Marwaha (2020), an adult must experience the following symptoms for at least 1-month: at least one re-experiencing symptom, at least one avoidance symptom, at least two mood and cognitive symptoms and at least two hyperarousal symptoms. Why a group of people develop PTSD while another group does not heralds the concept of etiological factors.
As classified by the American Psychiatric Association (2013), PTSD etiology is divided into pre-existing factors, peritraumatic factors and posttraumatic factors. Pre-existing factors include gender predilection (higher in women), prior or existing mental illness and prior exposure to a traumatic event (American Psychiatric Association, 2013; Lehavot et al., 2018). Peritraumatic factors include severity of the traumatic event and interpersonal violence while examples of posttraumatic factors include financial stress, lack of social support and generally unfavorable life events (American Psychiatric Association, 2013).
Epidemiology of PTSD
Mann and Marwaha (2020) note that traumatic events have a prevalence of about 60% to 80% in the lives of individuals. Post the trauma, 5-10% of the people suffer PTSD and the prevalence is higher in women than men (Lehavot et al., 2018; Mann & Marwaha, 2020). Further, the prevalence depends on the specific population. The population commonly studied for having a predilection for developing PTSD is the veterans.
PTSD is historically the most common mental health disorder among veterans. Worldwide epidemiology of PTSD among veterans is widely unstudied; however, a study conducted by Oveisi et al. (2018 Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT)) on the prevalence of PTSD among veterans of Tehran, capital of Iran, reveal a prevalence of 39%. Some of the environmental factors that predispose the veterans to re-experiencing the symptoms of PTSD include images of the martyrs on the walls, areas of the city named after martyrs and martyrdom of their chemical front partners (Oveisi et al., 2018).
Incidentally, Iran being epitheted a war zone, and having experienced 8-years of holy defense, there was a need to evaluate the mental health of the many veterans who reside there. Oveisi and colleagues therefore chose 172 veterans who participated in the war fronts from 1980-1982. Out of the 172 veterans, 67 of them (39%) were diagnosed with PTSD.
Even though the statistic is not a global representation, it is evident that a significant portion of the veterans suffer from PTSD, thereby necessitating helpful interventions. The study by Oveisi et al. (2018) further reveal a concomitant occurrence of other psychiatric disorders such as personality disorders, which include depression (12.2%), borderline (9.9%), narcissistic (7%) and paranoid (7%).
In a study conducted by Hines et al. (2014) on the prevalence of PTSD among the military groups in Iraq and Afghanistan which are war endemic zones, the findings reveal an estimate of 7.1% among the Afghanistan military personnel and a pooled estimate of 12.9% among the Iraqi military group. Further, the military groups deployed to both Afghanistan and Iraq had an estimated prevalence of 10.4%.
The study by Hines et al. (2014) do not largely deviate from the Mann and Marwaha (2020) prevalence of 5-10% among populations already exposed to trauma. Despite the differences in the prevalence as portrayed by different studies, attention to mental health among the veterans cannot be underestimated.
The treatment for PTSD can be both pharmacological and psychotherapeutic. According to the Department of Veteran Affairs Department of Defense [VA/DoD] (2017), psychotherapy is superior to pharmacotherapy in PTSD treatment and management. Two types of psychotherapy are used, trauma-focused and non-trauma focused (VA/DoD, 2017). The trauma focused psychotherapy is recommended by VA/DoD (2017) as the first line treatment for PTSD.
It involves reducing the symptoms of PTSD by targeting the thoughts, emotions, feelings and the memories related to the traumatic events. The trauma focused psychotherapy is superior in imparting change on PTSD symptoms while at the same time ensuring the effects of the improvements are felt for a long time (VA/DoD, 2017).
The commonly used trauma-focused psychotherapy includes prolonged exposure (PE) and cognitive processing therapy (CPT). However, due to the increasing use of technology in mental health, virtual reality therapy is increasingly embraced. According to VA/DoD (2017), pharmacology and non-trauma focused psychotherapy are only considered if the patient cannot access or should the patient decline the trauma-focused psychotherapy.
CPT in veterans with PTSD
CPT is a form of cognitive behavioral therapy. CPT aims at equipping the patient with skills to manage their distressing situations, thoughts, memories and emotions (VA/DoD, 2017). The process includes 12 sessions each lasting 90-minutes. However, it is possible to add the sessions and modify the durations depending on the patient preferences and needs (VA/DoD, 2017).
In a randomized control study to evaluate the efficacy of CPT in the management of veterans with PTSD with history of traumatic brain injuries, the findings reveal a significant reduction in the symptomatology of PTSD and improvement in the quality of life (Jak et al., 2019). Further, CPT combined with Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) improved the memory, attention and the cognitive functioning of the veterans (Jak et al., 2019).
However, due to the challenges with attending the counseling sessions such as far geographical proximity, socioeconomic status and currently due to the COVID-imposed restrictions of movement, VRT is an alternative intervention with involvement of technology.
VRT in veterans with PTSD
VRT is an emerging treatment modality for PTSD with limited studies on the efficacy and safety. VRT means that treatment process leverage digital platforms for the treatment of patients. In one of the studies by Loucks et al. (2019) to assess the feasibility of VRT among veterans with PTSD due to military sexual trauma, 15 participants (veterans) passed the eligibility criteria. Their mean age was 46-years and majority were females (73.4%). Of the 15 veterans, only 9 completed the study.
The patients were taken through a minimum of 6 to a maximum of 12 sessions of VRT. The findings of the study reveal a significant reduction in the clinician assessed symptoms and the patient reported depressive symptoms. The study thus proposed a shift in focus from the conventional interventions to emergent interventions such as VRT in the management of PTSD symptoms among veterans.
Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT) Learning Objectives
Learning Outcome 1: The students will be able to identify patients with PTSD symptoms and be able to make a diagnosis using the American Psychological Association DSM-5 and the Veteran Health Administration and Department of Defense Affairs.
Learning Outcome 2: The students will be able to identify in each patient, the predisposing factors for PTSD under the following headings: pre-existing factors, peritraumatic factors and the post traumatic factors.
Learning Outcome 3: Students will be able to identify the needs and preferences of PTSD patients and design appropriate treatment interventions and provide the rationale for choice in each patient.
Active Learning Strategies
As aforementioned, active learning strategies accord learners the opportunity to control the process. It is learner-oriented and has been associated with better outcomes as compared to passive techniques (Harris & Bacon, 2019). Teaching in higher education centers is transitioning from the old didactic lectures to student directed strategies such as problem based learning strategies, student directed group discussions, case studies and peer teaching (Harris & Bacon, 2019). Starting with a description of a case study hereafter, the details provided lay a foundation for how the students will participate in the other active learning strategies.
The patient (J.A) is a 47-year old male who retired voluntarily from the U.S Navy 6-months ago. He has served in the Operation Iraqi Freedom (OIF) for over 9-years after which he decided to voluntarily halt his employment. The patient, in the company of his wife presented with chief allegations of recurrent aversive memories of sexual assault for the past 2 years, nightmares for 1 ½ years and sleep disturbance for the past 1-year. These symptoms began while he was still in the OIF and have exacerbated since he quitted the Navy. The history of presenting illness is as described hereafter.
J.A reports to have been sexually assaulted by his senior non-commissioned officers for the 9-years he was serving in the U.S Navy. He reports repeated encounters, approximately 3 times a month of traumatic sexual assault by different senior officers. They stayed in hotel rooms with non-lockable doors and report that the senior officers would get into the rooms anytime to check on the status of their juniors.
The senior officers would get into the room heavily breathing and with mayhem and would switch off the lights. Reportedly they would shout ‘remove your clothes’. J.A reported to comply out of fear that he would be falsely charged with offences under the U.S Navy Discipline Legislation. “Majority of the junior officers complied for the same fear of being fired since most of them had young families to feed”, J.A reported. He reports that his last two years in service were tragic as he could repeatedly re-experience the traumatic sexual trauma via memories.
He would hear the officers shout, talk and would see the darkness in the room even during daytime. These events prompted him to quit his job before attaining the retirement age. Since then, the wife reports that he tends to avoid fellow men of nearly the same age and he has developed predilection for younger friends (children). He reports having attended the operation’s clinic where they were put under a group therapy and taught on management of their distressing symptoms without significant relief. Thereafter, he opted for early retirement
The patient also reports he has been having nightmares for the last one and a half years, where he re-experiences the traumatic sexual events via dreams. The wife reports that he often wakes up diaphoretic, shouting, crying and aggressive. He attributes his sleep disturbance to the nightmares. Initially while in the Navy, he reports they slept for 5-6 hours per night; however, since the initiation of the symptoms, he has had a difficulty in onset of sleep and even sustaining a 2-hour seamless sleep.
Therefore, he opts to stay in the sitting room watching the television throughout the night for fear that he would experience the same nightmares while sleeping. The wife reports that he is always on a low mood unlike 9-years ago when he was a jovial, social and a talkative person. He even avoids social gathering and has detached himself from the extended family. He stays at home throughout the day and has no interest in doing any activity or even helping the family with household chores.
On inquiring about his past medical history, he was diagnosed with Type 2 Diabetes Mellitus 10-years ago which is well controlled on Metformin 500mg BD. On analysis of the entire extended family, there are no psychopathologies detected such as substance abuse, divorce or encounter with the authorities (forensic history). He is married to one wife and blessed with two children who are schooling and living a healthy life.
Since his decision to quit the Navy, his early retirement package has been sustaining the family. The wife is a high school teacher and also provides for the family. On physical examination, the patient is in a fairly general condition, well hydrated and no pallor, jaundice, edema or lymphadenopathy is elicited. The vital signs are as follows BP: 127/94; Temperature: 36.7°C, RR: 22 breaths/minute; Pulse: 82 beats/minute. On mental status examination, the positive findings include a low mood, auditory and visual hallucinations and a neurovegetative dysfunction (sleep).
Importance of the Case Study
The case presented above depicts a quintessence of patients with PTSD presentation. From the case study, students can learn the various symptoms of the patients and the health care needs of the patients. A case study enables students to actively engage in their learning. It links basic sciences with clinical experiences and as such, has an advantage over the traditional didactic lectures (Ghasemi, Moonaghi & Heydari, 2020 Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT)).
Since case studies are clinical based scenarios, they prepare students for practice. Even though the students do not interact with real patients, they are able to visualize the case presented. The case study presented is about PTSD and is meant to hone critical thinking among the students. The aim is to enable them apply the theoretical knowledge into clinical practice.
The students are able to identify the health needs of the patient in the case which include relieving the symptoms and resumption of the normal social, occupational and functional capacity. Through the health needs, students can design appropriate interventions for the patient.
For example, having noted earlier the VA/DoD (2017) first line treatment recommendation for PTSD, this patient therefore requires a trauma-focused therapy. First, the patient will be taken through 12 sessions of CPT. Each session will take 90-minutes. Before the completion of the 12-sessions, there could be a possibility of halting the interventions following improvements in symptoms and the social and emotional functioning.
During each session of CPT, the patient is taught on how to manage their distressing thoughts and memories (VA/DoD, 2017). Following the current restrictions on movements, access to health facilities for counseling can be difficult. Therefore, VRT sessions would be ideal. During VRT, the intervening clinician leverages technology to access the patient (VA/DoD, 2017). This heralds the concept of Tele-health in mental care. However, due to digital gap, other patients fail to access internet or computers, an occurrence that derail the reliability of VRT and Tele-health interventions.
Discussion forum are a type of an active learning strategy. According to Ghasemi et al. (2020), this strategy consists of a group of students or learners who meet to share ideas, thoughts and to solve problems. The meetings can be physical (in person), or via conference calls, websites or through text messaging.
Apparently, due to the rise of technology use following the COVID-19 restrictions on movements, online discussion forums have thrived while physical discussion forums are slowly becoming obsolete (Ghasemi et al., 2020). The video conferencing software that have helped students to learn even during the restrictions include Zoom, join.me, GoToMeeting and Adobe Connect among others. In this case, the discussion areas would include the construction of the diagnostic formulation, the multi-axial diagnostic approach and the prognosis.
The diagnostic formulation for the case presented would be as follows: J.A, a 47-year old American male and a retired U.S Navy official presented with 2-years history of re-experiencing aversive memories on military sexual trauma, 1 ½ year history of nightmares and a 1-year history of sleep disturbance. There is no significant familial history of mental illnesses. The patient has had a past experience of group therapy where they were taught management of distressing symptoms; however, reported minimal improvement.
The multi-axial diagnostic approach is also another potential discussion topic. Using the theoretical knowledge, the students appreciate that the diagnostic approach includes Axis 1 to Axis 4. The axis 1 diagnostic is the psychiatric illness and the rationale. The second axis includes the developmental and personality disorders while the third axis includes physical disorders. The fourth axis includes the psychosocial stressors identified in the patient. J.A’s multi-axial diagnostic approach is as follows
- Post-Traumatic Stress Disorder – direct exposure to a traumatic sexual event; persistent intrusive thoughts on the traumatic event, nightmares, sleep disturbance, avoidance of male peers, persistent negative emotional state, and the symptoms have occurred for 2-years (more than 1-month)
- No developmental or personality behavior can be depicted from the case scenario
- Type 2 Diabetes Mellitus
- The psychosocial stressor that can be elicited from the case study include sexual assault
Moreover, determining the prognosis of the patient is a discussion topic that enables the students to engage in high order thinking. Prognosis, as defined by Mann and Marwaha (2020), refers to the factors that determine the eventual outcomes of the illness. The factors are diverse and can be good or bad. The topic therefore can also be a good assignment to equip the students with critical thinking skills.
Nearly all the topics included in the discussion forum are relevant for a written assignment. These assignments allow the students to search for databases related to the assigned topics. This therefore hones the research skills of the students. Nursing is a healthcare field rich in research, with most assignments designed to equip the students with skills to practice in the future (Ghasemi et al., 2020). The following questions can be included as part of the assignment:
- Identify the healthcare needs of the patient described in the case study
- Describe the predisposing factors for PTSD in the patient
- Describe an inter-professional care for the patient described in the case study
- Design an appropriate follow-up intervention to determine the post intervention prognosis of the patient
High Order Thinking Skills
The purpose of this study is not only to impart knowledge but also to equip the students with high order thinking skills (HOTS). To acquire the HOTS, active learning strategies as described above (case studies, discussion forums and written assignments) are used. Due to active engagement and participation of learners in the process, better outcomes are achieved. The four HOTS objectives that the course would like to achieve include application, analysis, evaluation and creation.
The application of theoretical knowledge into actual clinical practice is the aim of training healthcare professionals. The knowledge alone, without integration into practice is considered useless. In this case, the students are given a case study on PTSD, and are instructed to analyze the case and to answer a series of questions. The questions include clinical areas such as treatment options for the patients. Should the students meet patients with similar presentations in the future, they will be familiar with the cases.
All branches of nursing or medicine require research skills. There is a pervasive learning in clinical practice as clinicians are required to constantly evaluate the evidence before applying the same into practice (Harris & Bacon, 2019). Further, robust medical information and various medical references exist online for healthcare providers to analyze and synthesize into their daily practice (Harris & Bacon, 2019bCognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT)).
In this case, the students are instructed to search online articles regarding the topic. This exercise sharpens their research skills and also horns their decision-making capability since they have to choose the right evidence. To further improve their analytic skills, students can be asked to provide a research appraisal and annotated bibliography about the articles chosen.
Besides analysis, clinicians must also be equipped with evaluative skills. In healthcare, evaluation is essential in making a diagnosis. According to the Harris and Bacon (2019), a practitioner can complete an evaluation during the process of history taking, laboratory tests, imaging tests or just by observation. In psychiatry, the most important part that gives hints about the diagnosis is the history taking process.
In this case, students and clinicians must have active listening skills complimented by adequate knowledge to evaluate patients (Harris & Bacon, 2019). Finally, the course equips the students with the ability to create new information. Bloom’s taxonomy includes creation of new knowledge as part of the education reforms.
Creation of knowledge refers to the synthesis of information and ability to extrapolate information (Harris & Bacon, 2019). This skill is particularly important in nursing and medical practice and it enables colleagues embrace different opinions. For example, J.A is diagnosed with PTSD; however, a different professional might opine that the description fits the diagnosis of depression.
Principles and methods used in adult teaching are referred to as andragogy. In andragogy, learning is student-oriented and the learner does not depend on the teacher or the instructor (Mukhalalati & Taylor, 2019). This is different from pedagogy where the teacher is controlling the learning schedules and activities.
The student is the initiator of learning in andragogy (Mukhalalati & Taylor, 2019). Further, andragogy utilizes a more application-based curriculum which equips the learners with the appropriate knowledge and the high order thinking skills. The learners engage more in activities and tasks designed to help them solve problems unlike in pedagogy where the aim of the learning is to acquire the subject matter.
In this case, the elements of andragogy used include discussion forums and clinical-based scenarios. The discussion forums are student-oriented and require minimal supervision from the instructors. Students meet to discuss ideas and solve problems therefore boosting their critical thinking capacity. Further, clinical-based scenarios include a case study of a patient with a condition to be studied. The case study helps learners integrate theory with clinical practice (Harris 7 Bacon, 2019) which translates into a better patient care.
|Time Allotted||Teaching Strategy||Rationale and LO Linkage|
|1-5 minutes||Introduction: The students introduce their selves and give their expectations of the course
Students give their opinion on what they know about the topic (PTSD)
|The first few minutes of the class are introductory. This is a different course with a new lecturer. Students are therefore given time to introduce their selves and state their expected outcomes of the unit. The interaction helps create a friendly learning environment (Mukhalalati & Taylor, 2019). Students are further given time to state what they already know about the topic.|
|5-10 minutes||Topic Introduction: Definition and diagnosis
Epidemiology: Review of the worldwide prevalence of the PTSD and among specific populations (veterans). Students to be assigned the task of searching literature concerning the prevalence of PTSD among veterans in their nation
|L.O. 1. Students will be able to identify patients with PTSD symptoms and diagnose them according to the DSM-5. The DSM-5 is the standard and universal reference for diagnosing psychiatric patients (APA, 2013). The epidemiology of PTSD is useful in determining the burden of the disease. To improve their research skills, students are given an assignment to search for the epidemiology of PTSD among veterans in their nation
|10 minutes||Case Study Review: Students are given time to review the clinical based scenario
Group Discussion of the Case Scenario: Students group themselves into small study units
|L.O. 1. Students will be able to review the case study and provide a multi-axial diagnosis of the patient using the criteria provided by the APA (2013). This assesses the students’ ability to integrate the theory into practice.
Students discuss the case in their small study groups before making a presentation to the whole class. Each group has a representative who makes a presentation to the entire class.
|15-20 minutes||General Class Discussion: Each group’s representative makes a presentation to the class.
The general class is allowed to participate.
|L.O. 2. During class presentations, the group leaders emphasize on the predisposing factors under pre-existing, peritraumatic and posttraumatic events. All the students provide their input and this encourages Bloom’s taxonomy concept about creation of new knowledge (Harris & Bacon, 2019)
Until this stage, the input of the instructor is minimal. Andragogy requires the learner to direct the learning process (Mukhalalati & Taylor, 2019). The student directed learning is associated with HOTS such as application, evaluation, analysis and creation of new knowledge (Barris & Bacon, 2019 Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT))
|15 minutes||Written Assignment: During the last 15 minutes, students are given a paper to design treatment for the patient in the case study||L.O. 3. Within the final 15 minutes, students are given a 15-minute examination on the appropriate treatment for the patient. The answers will be analyzed in the next class and will be used as a basis for learning in the next lesson.
After the interaction with literature, students are expected to know the right treatments for the patients with PTSD. In the assignment, the tutor wants to determine whether the students are familiar with the first line treatments of PTSD. VA/DoD (2017) recommends trauma-focused psychotherapy before trying non-trauma focused psychotherapy or pharmacology.
Further, the assignment will be used to determine the strength and weakness of each student. In a classroom, each student has a different learning capability. The teacher should therefore approach each student separately depending on the learning needs (Harris & Bacon, 2019)
Cognitive Processing Therapy (CPT) vs Virtual Reality Therapy (VRT) References
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Frueh, B. C., Grubaugh, A. L., Yeager, D. E., & Magruder, K. M. (2009). Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics. The British Journal of Psychiatry: The Journal of Mental Science, 194(6), 515–520. https://doi.org/10.1192/bjp.bp.108.054700
Ghasemi, M. R., Moonaghi, H. K., & Heydari, A. (2020). Strategies for sustaining and enhancing nursing students’ engagement in academic and clinical settings: a narrative review. Korean Journal of Medical Education, 32(2), 103–117. https://doi.org/10.3946/kjme.2020.159
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Oveisi, K., Esmaeilimotlagh, M., Alizadeh, F., & Asadollahi Kheirabadi, M. (2018). To Study the Prevalence of Post-Traumatic Stress Disorder and its Comorbidity with personality disorders among veterans of Tehran. Journal of Humanities Insights, 2(01), 6–13. https://doi.org/10.22034/jhi.2018.61277
Wan, X., & Zeng, R. (2020). Guide for focused history taking. In Handbook of Clinical Diagnostics (pp. 113–114). Springer Singapore. https://doi.org/10.1007/978-981-13-7677-1_38
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