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1.
I
NT
RO
D
UCT
I
O
N
In
th
e
p
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3
0
y
ea
r
s
,
n
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m
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s
t
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ter
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tio
n
o
n
m
en
tal
as
w
ell
as
p
h
y
s
ical
h
ea
lt
h
[1
]
,
[
2]
.
T
h
e
b
asic
e
x
p
r
ess
i
v
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w
r
iti
n
g
p
ar
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ce
th
r
o
u
g
h
d
i
s
clo
s
u
r
e
w
r
it
in
g
[
3
]
.
I
n
1
9
8
6
,
t
h
is
w
r
iti
n
g
p
ar
ad
ig
m
w
as
te
s
ted
a
m
o
n
g
4
6
h
ea
lt
h
y
u
n
i
v
er
s
it
y
s
tu
d
e
n
ts
,
w
h
o
w
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e
as
k
ed
to
w
r
ite
ab
o
u
t
th
e
ir
th
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g
h
t
s
an
d
f
ee
li
n
g
s
r
elate
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to
t
h
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p
er
s
o
n
al
tr
au
m
atic
ex
p
er
ien
ce
f
o
r
2
0
m
i
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tes
p
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r
s
ess
io
n
o
n
f
o
u
r
co
n
s
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u
ti
v
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d
ay
s
.
St
u
d
en
t
s
in
e
x
p
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v
e
w
r
iti
n
g
co
n
d
itio
n
s
h
o
w
ed
s
i
g
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if
ican
t
l
y
f
e
w
e
r
h
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alth
ce
n
ter
v
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s
it
s
th
a
n
s
tu
d
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ts
in
co
n
tr
o
l
w
r
iti
n
g
in
a
s
i
x
m
o
n
th
s
f
o
llo
w
-
u
p
.
T
h
e
r
esear
ch
h
as p
r
o
v
id
ed
s
o
m
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p
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eli
m
i
n
ar
y
i
n
s
ig
h
t o
n
t
h
e
r
an
g
e
o
f
p
h
y
s
io
lo
g
ical
b
en
e
f
i
ts
o
f
e
x
p
r
ess
iv
e
w
r
iti
n
g
.
I
n
t
h
e
b
r
o
ad
er
co
n
tex
t,
s
tu
d
i
es
i
n
t
h
e
la
s
t
t
h
r
ee
d
ec
ad
es
s
h
o
w
ed
t
h
at
t
h
e
p
r
ac
tice
o
f
ex
p
r
ess
i
v
e
w
r
iti
n
g
ca
n
lead
to
i
m
p
r
o
v
e
m
en
t
i
n
lu
n
g
a
n
d
li
v
er
f
u
n
ctio
n
i
n
g
[4
]
,
[
5]
,
d
ec
r
ea
s
ed
b
lo
o
d
p
r
ess
u
r
e
[
6
]
an
d
e
v
en
en
h
a
n
ce
d
i
m
m
u
n
e
s
y
s
te
m
f
u
n
ct
io
n
i
n
g
[
7
]
.
I
n
ad
d
itio
n
,
ex
p
r
ess
i
v
e
w
r
iti
n
g
also
r
e
s
u
lt
s
i
n
s
i
g
n
i
f
ica
n
t
i
m
p
r
o
v
e
m
en
t
in
n
o
n
-
h
ea
lt
h
r
e
lated
o
u
tco
m
e
s
s
u
ch
as
b
etter
ac
ad
e
m
ic
p
er
f
o
r
m
a
n
ce
[
8
]
,
r
ed
u
ce
d
ab
s
en
teei
s
m
f
r
o
m
w
o
r
k
[
4
]
an
d
e
n
h
a
n
ce
d
w
o
r
k
in
g
m
e
m
o
r
y
[
9
]
.
Fro
m
a
p
s
y
ch
o
lo
g
ical
p
er
s
p
ec
tiv
e,
i
t
w
a
s
e
v
id
en
t
t
h
at
ex
p
r
ess
i
v
e
w
r
iti
n
g
ca
n
lead
to
b
etter
p
s
y
c
h
o
lo
g
ical
o
u
tco
m
e
s
,
s
u
c
h
as
i
m
p
r
o
v
e
m
e
n
t
i
n
p
o
s
t
-
tr
au
m
at
ic
g
r
o
w
th
[
1
0
]
,
d
ec
r
ea
s
ed
ten
d
en
c
y
to
r
u
m
i
n
ate
[
1
1
]
an
d
d
i
m
i
n
is
h
e
d
f
ee
lin
g
s
o
f
a
n
g
er
[
1
2
]
.
So
m
e
o
f
t
h
e
p
o
s
s
ib
le
m
ec
h
a
n
i
s
m
s
i
n
v
o
l
v
ed
m
i
g
h
t
b
e
e
m
o
tio
n
al
ca
t
h
ar
s
is
,
e
m
o
tio
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al
co
n
f
r
o
n
tatio
n
an
d
r
ep
ea
ted
ex
p
o
s
u
r
e
th
r
o
u
g
h
ex
p
r
ess
i
v
e
w
r
iti
n
g
[
1
]
.
Ho
w
e
v
er
,
th
e
f
in
d
i
n
g
s
f
o
r
p
s
y
ch
o
l
o
g
ical
b
en
e
f
its
ar
e
n
o
t
as
r
o
b
u
s
t
a
s
co
m
p
ar
ed
to
p
h
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s
ical
h
ea
lt
h
,
as
th
er
e
w
er
e
in
co
n
s
i
s
te
n
t
r
esu
l
ts
t
h
at
p
ar
ticip
an
ts
i
n
ex
p
r
ess
i
v
e
w
r
iti
n
g
co
n
d
itio
n
w
ill
h
a
v
e
s
ig
n
i
f
ica
n
t g
r
ea
ter
i
m
p
r
o
v
e
m
e
n
t th
a
n
t
h
o
s
e
i
n
co
n
tr
o
l c
o
n
d
iti
o
n
[2
]
,
[
1
3
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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N:
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8
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I
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t.
J
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P
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Hea
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Sci.,
Vo
l.
1
0
,
No
.
2
,
J
u
n
e
20
21
:
4
33
–
4
44
434
Fro
m
a
th
er
ap
eu
tic
p
er
s
p
ec
tiv
e,
w
r
iti
n
g
i
n
ter
v
e
n
tio
n
o
f
ten
s
er
v
e
s
as
a
n
o
n
-
v
er
b
al
to
o
l
f
o
r
s
u
p
p
le
m
e
n
ti
n
g
tr
ad
itio
n
al
p
s
y
ch
o
t
h
er
ap
y
[
1
4
]
th
a
t
e
n
ab
le
s
clie
n
ts
to
r
estr
u
ct
u
r
e
a
n
d
m
ak
e
s
e
n
s
e
o
f
t
h
eir
ex
p
er
ien
ce
.
E
x
p
r
ess
i
v
e
w
r
i
tin
g
is
a
lo
w
co
s
t
an
d
ti
m
e
ef
f
ici
en
t
p
s
y
c
h
o
lo
g
ical
i
n
ter
v
e
n
tio
n
th
at
is
ap
p
licab
le
to
b
o
th
clin
ical
a
n
d
n
o
n
-
cl
in
ica
l
p
o
p
u
latio
n
s
[
1
3
]
.
I
t
is
a
s
el
f
-
h
elp
tec
h
n
iq
u
e
t
h
at
d
o
es
n
o
t
d
ir
ec
tl
y
i
n
v
o
l
v
e
t
h
e
p
r
esen
ce
o
f
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s
y
c
h
o
th
er
ap
is
t
s
,
an
d
it
allo
w
s
i
n
ter
n
a
l
d
ia
lo
g
u
e
w
it
h
o
n
e
s
elf
.
F
u
r
th
er
m
o
r
e,
t
h
i
s
w
r
iti
n
g
tech
n
iq
u
e
p
r
o
v
id
es
o
p
p
o
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tu
n
it
y
f
o
r
in
tr
o
s
p
ec
tio
n
a
n
d
ca
th
a
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s
is
w
it
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u
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f
ea
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o
f
ev
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an
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j
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m
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f
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s
[
15]
.
E
x
p
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w
r
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n
g
also
h
elp
s
i
n
d
i
v
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s
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r
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u
r
ce
s
,
s
u
c
h
as
i
m
a
g
in
a
tio
n
a
n
d
cr
ea
tiv
it
y
to
f
ac
ilit
ate
th
e
i
n
te
g
r
atio
n
o
f
b
o
th
th
e
e
m
o
tio
n
a
l
an
d
co
g
n
iti
v
e
co
m
p
o
n
e
n
t
s
o
f
li
f
e
ex
p
er
ien
ce
s
[
1
6
]
.
Hen
ce
,
ex
p
r
ess
i
v
e
w
r
i
tin
g
i
n
ter
v
e
n
tio
n
co
n
tai
n
s
h
ig
h
th
er
ap
eu
tic
p
o
ten
ti
al
f
o
r
in
d
iv
id
u
a
ls
to
h
ea
l f
r
o
m
tr
au
m
atic
as
w
e
ll a
s
s
tr
ess
f
u
l e
x
p
er
ien
ce
.
Ho
w
e
v
er
,
it
w
a
s
al
s
o
s
u
g
g
e
s
ted
th
a
t
w
r
iti
n
g
ab
o
u
t
n
e
g
a
tiv
e
e
x
p
er
ien
ce
m
i
g
h
t
b
e
e
m
o
tio
n
all
y
d
em
a
n
d
i
n
g
f
o
r
s
o
m
e
o
f
th
e
in
d
iv
id
u
al
s
[
1
7
]
,
b
ec
au
s
e
th
er
e
w
o
u
ld
b
e
an
i
m
m
ed
iate
i
n
cr
ea
s
e
in
n
e
g
ati
v
e
a
f
f
ec
t,
d
is
tr
ess
a
n
d
n
e
g
ati
v
e
p
h
y
s
ical
s
y
m
p
to
m
s
i
n
e
x
p
r
ess
iv
e
w
r
iti
n
g
co
n
d
itio
n
co
m
p
ar
ed
to
co
n
tr
o
l
co
n
d
itio
n
w
h
e
n
in
d
iv
id
u
als
n
e
ed
to
co
n
f
r
o
n
t
th
eir
u
n
p
lea
s
an
t
ex
p
er
ie
n
ce
f
o
r
th
e
f
ir
s
t
ti
m
e
[
1
]
,
ev
e
n
t
h
o
u
g
h
t
h
e
n
eg
a
tiv
e
ef
f
ec
ts
w
i
ll
d
i
m
in
i
s
h
o
v
er
ti
m
e
[
1
8
]
.
A
n
o
t
h
er
m
eth
o
d
o
f
ex
p
r
ess
i
v
e
w
r
iti
n
g
w
h
ich
f
o
c
u
s
e
s
o
n
p
o
s
iti
v
e
li
f
e
ex
p
er
ien
ce
w
a
s
in
tr
o
d
u
ce
d
w
it
h
e
x
p
ec
tatio
n
th
at
it
m
i
g
h
t
i
n
cr
ea
s
e
t
h
e
p
o
s
iti
v
e
f
ee
li
n
g
s
a
n
d
ev
e
n
tu
a
ll
y
i
m
p
r
o
v
e
t
h
e
s
e
n
s
e
o
f
w
e
ll
-
b
ein
g
[
1
9
]
.
On
e
o
f
t
h
e
p
o
s
s
ib
le
u
n
d
er
l
y
i
n
g
m
ec
h
a
n
is
m
s
m
ig
h
t
b
e
t
h
at
p
o
s
iti
v
e
ex
p
er
ien
ce
w
r
iti
n
g
h
elp
s
to
r
e
co
v
er
g
o
o
d
m
e
m
o
r
ie
s
t
h
at
ar
e
s
u
p
p
r
ess
ed
,
an
d
t
h
i
s
en
ab
le
s
in
d
iv
id
u
als
to
g
ai
n
m
ea
n
in
g
a
n
d
p
u
r
p
o
s
e
f
r
o
m
t
h
eir
d
is
clo
s
u
r
e
w
r
it
in
g
[
1
8
]
.
T
h
e
d
ev
elo
p
m
en
t
is
also
r
ela
ted
to
th
e
p
o
s
itiv
e
p
s
y
ch
o
lo
g
y
m
o
v
e
m
e
n
t,
in
w
h
ich
m
a
n
y
p
s
y
c
h
o
lo
g
ical
i
n
ter
v
en
t
io
n
s
ar
e
d
ev
elo
p
ed
w
it
h
th
e
f
o
c
u
s
o
n
w
ell
-
b
ein
g
,
p
er
s
o
n
al
s
tr
en
g
t
h
a
n
d
p
o
s
itiv
e
e
m
o
tio
n
s
[
2
0
]
.
I
t
w
a
s
d
is
co
v
er
ed
t
h
at
p
ar
ticip
an
ts
w
h
o
w
r
o
te
ab
o
u
t
in
te
n
s
el
y
p
o
s
i
tiv
e
e
x
p
er
ien
ce
s
w
o
u
ld
h
a
v
e
s
i
g
n
i
f
ica
n
tl
y
m
o
r
e
p
o
s
itiv
e
m
o
o
d
s
an
d
f
e
w
er
h
ea
lt
h
ce
n
ter
v
i
s
its
co
m
p
ar
ed
to
p
ar
ticip
an
ts
in
co
n
tr
o
l
co
n
d
itio
n
[
1
9
]
,
an
d
it
w
a
s
also
ev
id
en
t
t
h
at
w
r
iti
n
g
o
u
t
o
n
e’
s
b
est
p
o
s
s
ib
le
f
u
tu
r
e
s
el
v
es
w
as
les
s
u
p
s
etti
n
g
t
h
a
n
w
r
iti
n
g
ab
o
u
t
tr
au
m
a
a
n
d
ca
n
lead
to
s
i
g
n
if
ica
n
tl
y
b
e
tter
s
u
b
j
ec
tiv
e
w
ell
-
b
ein
g
[
2
1
]
.
T
h
ese
f
in
d
i
n
g
s
s
u
g
g
es
ted
th
at
d
is
clo
s
u
r
e
w
r
it
in
g
m
i
g
h
t
n
o
t
n
ec
es
s
ar
il
y
n
e
ed
to
b
e
in
ten
s
el
y
tr
au
m
a
-
f
o
cu
s
ed
to
b
e
ef
f
ec
tiv
e
f
o
r
in
d
i
v
id
u
al
s
,
an
d
t
h
e
u
n
d
er
l
y
in
g
m
ec
h
an
i
s
m
b
y
w
h
ic
h
ex
p
r
ess
i
v
e
w
r
iti
n
g
o
p
er
ates is also
ch
alle
n
g
ed
[
2
2
]
.
T
h
eo
r
etica
l f
r
a
m
e
w
o
r
k
an
d
lit
er
atu
r
e
r
ev
ie
w
T
h
e
m
ai
n
d
if
f
er
en
ce
b
et
w
ee
n
p
o
s
itiv
e
ex
p
er
ien
ce
w
r
iti
n
g
(
P
E
W
)
an
d
n
eg
ati
v
e
ex
p
er
ien
ce
w
r
iti
n
g
(
NE
W
)
is
th
e
af
f
ec
t
,
o
r
f
ee
lin
g
,
th
at
is
i
n
d
u
ce
d
d
u
r
in
g
t
h
e
co
g
n
i
tiv
e
p
r
o
ce
s
s
o
f
e
n
g
ag
i
n
g
in
ex
p
r
ess
i
v
e
w
r
itin
g
[
1
9
]
.
I
n
d
iv
id
u
al
s
w
h
o
w
r
o
te
a
b
o
u
t
in
te
n
s
el
y
n
eg
a
tiv
e
e
x
p
er
i
en
ce
s
m
i
g
h
t
h
a
v
e
h
ig
h
i
n
te
n
s
it
y
n
e
g
ati
v
e
f
ee
li
n
g
s
w
h
er
ea
s
i
n
d
iv
id
u
als
w
h
o
w
r
o
te
ab
o
u
t
p
o
s
itiv
e
e
x
p
er
ien
ce
s
m
i
g
h
t
h
a
v
e
h
i
g
h
in
ten
s
it
y
p
o
s
itiv
e
f
ee
li
n
g
s
af
ter
w
r
iti
n
g
[
2
3
]
.
T
h
er
e
ar
e
tw
o
p
o
s
s
ib
le
p
ath
w
a
y
s
o
f
t
h
i
s
m
ec
h
an
i
s
m
,
in
w
h
ic
h
o
n
e
o
f
t
h
e
p
ath
w
a
y
s
is
t
h
r
o
u
g
h
th
e
s
y
s
te
m
atic
-
h
eu
r
i
s
tic
m
o
d
e
l
o
f
in
f
o
r
m
atio
n
p
r
o
ce
s
s
i
n
g
[
2
4
]
:
th
e
n
ar
r
atio
n
o
f
n
e
g
ativ
e
e
x
p
er
ien
ce
s
lead
s
to
an
i
n
-
d
ep
t
h
an
a
l
y
s
is
o
f
t
h
o
u
g
h
ts
a
n
d
f
ee
li
n
g
s
b
ec
au
s
e
n
eg
a
tiv
e
e
m
o
tio
n
s
ar
e
o
f
te
n
a
s
s
o
ci
ated
w
it
h
d
elib
er
ate
s
y
s
te
m
a
tic
p
r
o
ce
s
s
in
g
o
f
i
n
f
o
r
m
atio
n
,
p
o
s
iti
v
e
e
m
o
tio
n
s
el
ic
ited
f
r
o
m
P
E
W
o
f
ten
lead
s
to
h
eu
r
i
s
tic
ap
p
r
o
ac
h
,
w
h
er
ea
s
a
n
in
d
i
v
id
u
al
m
i
g
h
t
u
s
e
m
e
n
tal
s
h
o
r
tcu
t
s
to
in
ter
p
r
et
th
eir
ex
p
er
ie
n
ce
s
,
h
e
n
ce
les
s
lik
el
y
to
g
ai
n
d
ee
p
in
s
i
g
h
t i
n
to
th
eir
ex
p
er
ie
n
ce
[
1
9
]
.
Nev
er
th
e
less
,
it
w
a
s
ar
g
u
ed
t
h
at
th
e
s
y
s
te
m
a
tic
-
h
e
u
r
is
tic
m
o
d
el
m
i
g
h
t
n
o
t
ac
cu
r
atel
y
ca
p
tu
r
e
th
e
ess
e
n
ce
o
f
P
E
W
,
as
en
g
a
g
in
g
i
n
P
E
W
in
v
o
l
v
es
s
i
g
n
i
f
ica
n
tl
y
h
ig
h
er
n
u
m
b
er
s
o
f
in
s
i
g
h
t
f
u
l
w
o
r
d
s
s
u
c
h
a
s
“u
n
d
er
s
ta
n
d
,
r
ea
lize
an
d
r
ea
s
o
n
”
co
m
p
ar
ed
to
NE
W
an
d
co
n
tr
o
l
co
n
d
itio
n
[
2
5
]
.
T
h
er
ef
o
r
e,
an
o
th
er
p
ath
w
a
y
m
o
d
el
o
f
af
f
ec
ti
v
e
an
d
co
g
n
iti
v
e
p
r
o
ce
s
s
in
g
,
“
b
r
o
ad
en
an
d
b
u
ild
”
m
o
d
el
o
f
p
o
s
iti
v
e
e
m
o
t
i
o
n
,
w
a
s
in
tr
o
d
u
ce
d
;
th
is
m
o
d
el
s
u
g
g
ested
th
at
p
o
s
iti
v
e
e
x
a
m
in
at
io
n
o
f
i
n
ter
n
a
l
s
tate
m
i
g
h
t
b
r
o
ad
en
a
n
i
n
d
i
v
id
u
al
's
co
p
in
g
a
n
d
co
g
n
itio
n
p
r
o
ce
s
s
es,
e
n
ab
li
n
g
o
n
e
to
av
o
id
n
e
g
ati
v
e
r
u
m
i
n
at
io
n
an
d
co
g
n
it
iv
e
b
ia
s
es
t
h
at
o
f
ten
lead
to
o
n
s
e
t
o
f
d
ep
r
ess
io
n
[
1
1
]
.
T
h
is
is
b
e
ca
u
s
e
i
n
d
iv
id
u
als
e
x
p
er
ien
ci
n
g
p
o
s
iti
v
e
e
m
o
tio
n
s
w
o
u
ld
ad
o
p
t
a
g
lo
b
al
m
in
d
s
et
in
t
h
e
atte
n
tio
n
a
l
p
r
o
ce
s
s
[
2
6
]
,
an
d
it
led
t
h
e
m
to
p
a
y
m
o
r
e
atten
tio
n
to
th
e
w
h
o
le
p
ict
u
r
e
o
f
th
e
ex
p
er
ien
ce
,
w
it
h
o
u
t
f
ix
at
in
g
o
r
r
u
m
in
a
tin
g
o
n
ce
r
tai
n
d
etails
[
2
7
]
.
A
lt
er
n
ativ
e
l
y
,
i
n
d
iv
id
u
als
w
h
o
e
x
p
er
ien
ce
n
eg
at
iv
e
e
m
o
tio
n
s
s
u
ch
a
s
a
n
g
er
a
n
d
d
is
tr
ess
ten
d
to
n
ar
r
o
w
t
h
eir
at
ten
tio
n
a
l
f
o
c
u
s
o
n
p
ar
ticu
lar
i
n
f
o
r
m
atio
n
,
h
a
v
in
g
g
r
ea
ter
d
if
f
icu
l
ties
i
n
n
o
tici
n
g
an
d
o
v
er
co
m
i
n
g
t
h
e
e
m
o
t
io
n
al
ad
v
er
s
it
y
[
2
8
]
.
T
h
is
m
o
d
el
also
s
u
g
g
es
ted
th
e
b
r
o
ad
en
in
g
o
f
t
h
o
u
g
h
t
p
r
o
ce
s
s
es
tr
ig
g
er
ed
b
y
p
r
ev
io
u
s
p
o
s
itiv
e
ex
p
er
ien
ce
m
i
g
h
t
f
ac
ilit
ate
s
u
b
s
eq
u
en
t
co
p
i
n
g
p
r
o
ce
s
s
e
s
,
e
n
h
an
ci
n
g
a
n
i
n
d
iv
id
u
al
'
s
p
s
y
c
h
o
lo
g
i
ca
l
w
ell
-
b
ein
g
o
v
er
ti
m
e
[
2
9
]
b
y
cr
ea
ti
n
g
a
n
u
p
w
ar
d
s
p
ir
al
th
at
s
er
v
e
s
as
a
b
u
f
f
er
f
o
r
d
ep
r
ess
ed
m
o
o
d
[
3
0
]
.
T
h
is
is
s
i
m
ilar
to
th
e
b
u
ild
i
n
g
asp
ec
t
o
f
t
h
e
m
o
d
el,
w
h
ic
h
s
u
g
g
ested
th
at
t
h
e
b
r
o
ad
en
in
g
p
r
o
ce
s
s
ca
n
le
ad
to
en
d
u
r
in
g
an
d
p
er
m
a
n
e
n
t
ch
a
n
g
e
s
in
o
n
e
’
s
p
er
s
o
n
al
co
p
in
g
r
eso
u
r
ce
s
an
d
cu
lti
v
ati
n
g
r
esi
lien
ce
[
3
1
]
;
th
e
r
eb
y
,
th
e
r
ep
ea
ted
p
r
ac
tice
P
E
W
m
i
g
h
t
e
v
e
n
tu
a
ll
y
r
ed
u
ce
t
h
e
d
ep
r
ess
i
v
e
s
y
m
p
to
m
s
,
en
h
a
n
ce
o
n
e’
s
e
m
o
tio
n
al
w
e
ll
-
b
ei
n
g
,
in
cr
ea
s
e
p
o
s
iti
v
e
af
f
ec
t a
n
d
s
e
r
v
e
as a
co
p
in
g
r
eso
u
r
ce
f
o
r
in
d
iv
id
u
al
s
to
co
p
e
w
ith
t
h
eir
li
f
e
ev
en
t
s
[
3
2
]
.
W
h
ile
NE
W
w
as
o
f
te
n
r
ep
o
r
ted
to
p
r
ed
ict
b
etter
p
s
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c
h
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an
d
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y
s
ical
o
u
tco
m
es
th
an
co
n
tr
o
l
co
n
d
iti
on
[
1
]
,
[
2
]
th
er
e
is
s
til
l
in
s
u
f
f
icien
t
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v
id
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a
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ef
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y
o
f
P
E
W
o
n
t
h
e
s
a
m
e
f
ea
t
u
r
es.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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.
P
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Hea
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Sci.
I
SS
N:
2
2
5
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-
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C
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435
A
t
t
h
e
s
a
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e
ti
m
e,
s
t
u
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ies
co
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p
ar
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an
d
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also
s
h
o
w
ed
co
n
tr
ad
icto
r
y
f
i
n
d
in
g
s
[
1
9
]
,
[
2
5
]
.
Fo
r
in
s
tan
ce
,
a
s
ig
n
if
ica
n
t
in
cr
ea
s
e
i
n
p
o
s
itiv
e
e
m
o
tio
n
s
in
P
E
W
co
n
d
itio
n
co
m
p
ar
ed
to
NE
W
an
d
co
n
tr
o
l
co
n
d
itio
n
a
m
o
n
g
p
ar
t
icip
an
ts
w
h
o
ex
p
er
ie
n
ce
d
r
el
atio
n
s
h
ip
d
is
s
o
lu
t
io
n
[
3
3
]
;
wh
ile
a
n
o
t
h
er
s
t
u
d
y
r
ep
o
r
ted
th
at
P
E
W
w
as
in
f
er
io
r
to
NE
W
in
r
ed
u
c
in
g
a
n
x
iet
y
a
n
d
s
tr
ess
f
o
r
p
ar
ticip
an
ts
w
it
h
m
i
ld
m
o
o
d
d
is
o
r
d
er
s
[
2
2
]
.
I
n
ad
d
itio
n
,
w
h
ile
m
an
y
s
t
u
d
ies
ab
o
u
t
P
E
W
an
d
NE
W
w
er
e
co
n
d
u
cted
i
n
lab
o
r
ato
r
y
s
etti
n
g
s
,
s
o
m
e
s
tu
d
ie
s
h
a
v
e
s
u
g
g
ested
th
at
o
n
lin
e
w
r
iti
n
g
in
ter
v
en
tio
n
m
ig
h
t
b
e
m
o
r
e
co
n
v
en
ie
n
t
an
d
ac
ce
s
s
ib
le
to
a
lar
g
er
p
o
p
u
latio
n
t
h
a
n
lab
o
r
ato
r
y
i
n
ter
v
en
tio
n
[
2
2
]
,
[
3
4
]
,
esp
ec
iall
y
d
u
r
i
n
g
th
e
c
u
r
r
en
t
C
OVI
D
-
1
9
p
an
d
e
m
ic
[
3
5
]
.
T
h
is
cu
r
r
en
t
s
t
u
d
y
at
te
m
p
t
s
t
o
f
ill
in
t
h
e
p
r
ev
io
u
s
g
ap
b
y
in
tr
o
d
u
cin
g
o
n
l
in
e
w
r
iti
n
g
i
n
ter
v
e
n
tio
n
w
it
h
t
w
o
t
y
p
e
s
o
f
e
x
p
r
ess
i
v
e
w
r
iti
n
g
a
n
d
o
n
e
co
n
tr
o
l
co
n
d
i
tio
n
to
u
n
d
er
g
r
ad
u
ates
i
n
a
p
r
iv
ate
u
n
i
v
er
s
it
y
i
n
Ma
la
y
s
ia.
T
h
e
p
ar
ticip
an
ts
w
er
e
tak
en
f
r
o
m
t
h
is
g
r
o
u
p
b
ec
au
s
e
th
e
y
w
er
e
r
ep
o
r
ted
to
b
e
ex
p
o
s
ed
to
th
e
h
ig
h
e
s
t
r
is
k
s
o
f
d
ev
elo
p
in
g
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
a
m
o
n
g
y
o
u
n
g
ad
u
lt
s
in
th
e
co
u
n
tr
y
o
f
Ma
la
y
s
ia
[
3
6
]
.
T
h
e
y
ar
e
co
n
s
tan
t
l
y
d
is
tr
ess
ed
b
y
i
s
s
u
e
s
s
u
ch
a
s
ac
ad
e
m
ic
p
er
f
o
r
m
an
ce
,
f
i
n
an
c
i
al
co
n
s
tr
ain
t,
a
d
j
u
s
t
m
e
n
t
p
r
o
b
lem
s
an
d
lack
o
f
p
o
s
itiv
e
co
p
in
g
s
tr
ateg
y
.
He
n
ce
,
it
is
i
m
p
o
r
tan
t
to
d
eter
m
in
e
w
h
ic
h
t
y
p
e
o
f
d
is
clo
s
u
r
e
w
r
iti
n
g
in
ter
v
e
n
tio
n
ca
n
s
er
v
e
as
a
t
h
e
r
ap
eu
tic
to
o
l
f
o
r
en
h
an
ci
n
g
th
eir
m
e
n
tal
h
ea
lt
h
,
an
d
p
o
s
s
ib
ly
r
ed
u
ce
t
h
e
r
ate
o
f
ge
tti
n
g
cli
n
ical
d
ep
r
ess
io
n
d
u
r
in
g
th
eir
ter
t
iar
y
ed
u
ca
tio
n
.
Mo
r
eo
v
er
,
th
is
r
esear
c
h
m
i
g
h
t
also
p
r
o
v
id
e
s
o
m
e
in
s
i
g
h
ts
o
n
t
h
e
p
at
h
w
a
y
s
b
y
wh
ich
P
E
W
an
d
NE
W
o
p
er
ates,
h
e
n
ce
co
n
tr
ib
u
ti
n
g
to
t
h
e
liter
atu
r
e
o
f
th
eo
r
etica
l
m
ec
h
a
n
i
s
m
s
o
f
e
x
p
r
ess
i
v
e
w
r
i
tin
g
.
2.
RE
S
E
ARCH
M
E
T
H
O
D
2
.
1
.
Desig
n
o
f
t
he
ex
peri
m
e
nt
N
o
n
eq
u
i
v
alen
t
co
n
tr
o
l
g
r
o
u
p
p
r
e
-
test
p
o
s
t
-
te
s
t
d
esi
g
n
w
a
s
u
s
ed
to
i
n
v
est
ig
ate
t
h
e
e
f
f
ec
ti
v
en
e
s
s
o
f
ex
p
r
ess
i
v
e
w
r
iti
n
g
o
n
r
ed
u
ci
n
g
th
e
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
a
m
o
n
g
s
t
u
d
en
ts
o
f
a
p
r
i
v
ate
u
n
iv
er
s
it
y
i
n
Ma
la
y
s
ia
.
T
h
e
d
esig
n
w
as
c
h
o
s
e
n
d
u
e
t
o
its
f
ea
tu
r
e
i
n
co
m
p
ar
i
n
g
t
h
e
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
s
co
r
e
s
b
ef
o
r
e
an
d
a
f
ter
r
ec
eiv
in
g
t
h
e
tr
ea
t
m
e
n
t,
a
n
d
also
co
m
p
ar
ed
th
e
s
co
r
es
d
if
f
er
en
ce
s
to
t
h
e
n
o
n
eq
u
i
v
ale
n
t
co
n
tr
o
l
g
r
o
u
p
[
3
7
]
.
Ho
w
e
v
er
,
th
er
e
w
a
s
n
o
r
an
d
o
m
a
s
s
i
g
n
m
en
t
i
n
th
i
s
s
t
u
d
y
d
u
e
to
th
e
co
n
s
tr
ain
t
o
f
th
e
o
n
lin
e
r
esear
ch
p
latf
o
r
m
as p
ar
ticip
an
ts
w
er
e
allo
w
ed
to
ch
o
o
s
e
th
eir
o
w
n
s
lo
t
s
.
T
h
e
in
d
ep
en
d
en
t
v
ar
iab
le
(
I
V
)
in
t
h
i
s
s
tu
d
y
w
a
s
t
h
e
e
x
p
r
ess
i
v
e
w
r
iti
n
g
,
w
h
ic
h
co
n
s
is
te
d
o
f
t
h
r
ee
lev
els
:
p
o
s
iti
v
e
e
x
p
er
ien
ce
wr
itin
g
(
P
E
W
)
,
n
eg
ati
v
e
ex
p
er
ien
ce
w
r
iti
n
g
(
NE
W
)
an
d
co
n
tr
o
l
w
r
iti
n
g
(
C
W
)
co
n
d
itio
n
s
.
T
h
e
I
V
m
a
n
ip
u
lat
i
o
n
w
as
co
n
d
u
cted
b
et
w
ee
n
-
s
u
b
j
ec
ts
as
p
ar
ticip
an
ts
w
i
ll
b
e
ass
i
g
n
ed
w
i
th
o
n
l
y
o
n
e
o
f
th
e
co
n
d
itio
n
s
,
an
d
r
eq
u
ir
ed
to
p
er
f
o
r
m
th
e
s
a
m
e
w
r
i
tin
g
co
n
d
itio
n
o
n
th
e
o
n
l
in
e
wo
r
k
s
h
ee
t
f
o
r
a
to
tal
o
f
th
r
ee
s
es
s
io
n
s
.
T
h
e
p
r
i
m
ar
y
d
ep
en
d
en
t
v
ar
iab
le
(
DV)
was
th
e
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
,
w
h
ic
h
w
as
m
ea
s
u
r
ed
at
th
e
b
eg
i
n
n
i
n
g
o
f
t
h
e
f
ir
s
t
s
ess
io
n
o
f
w
r
it
in
g
i
n
ter
v
e
n
tio
n
(
p
r
e
-
test
)
a
n
d
at
th
e
e
n
d
o
f
t
h
e
th
ir
d
s
ess
io
n
(
p
o
s
ttes
t)
.
I
n
ad
d
itio
n
,
t
h
e
p
ar
ticip
an
ts
’
a
f
f
ec
t
w
a
s
i
n
cl
u
d
ed
as
a
m
an
ip
u
latio
n
c
h
ec
k
f
o
r
t
h
e
DV.
Af
f
ec
t
w
as
m
ea
s
u
r
ed
b
y
e
m
p
lo
y
in
g
th
e
p
o
s
itiv
e
af
f
ec
t
an
d
n
e
g
ati
v
e
a
f
f
ec
t sc
h
ed
u
le
(
P
A
N
AS)
[
3
8
]
p
r
io
r
to
an
d
a
f
ter
ea
c
h
w
r
iti
n
g
s
e
s
s
io
n
.
2
.
2
.
M
a
t
er
ia
ls
S
m
y
t
h
a
n
d
P
en
n
eb
a
k
er
[
3
9
]
d
ef
i
n
e
ex
p
r
es
s
i
v
e
w
r
iti
n
g
as
th
e
tech
n
iq
u
e
f
o
r
i
n
d
iv
id
u
als
to
w
r
ite
ab
o
u
t
th
eir
th
o
u
g
h
ts
a
n
d
f
ee
li
n
g
s
ab
o
u
t
tr
au
m
atic
e
x
p
er
ien
ce
s
o
r
p
e
r
s
o
n
al
is
s
u
es
f
r
ee
l
y
,
w
i
th
o
u
t
f
o
cu
s
in
g
o
n
g
r
a
m
m
atica
l
o
r
s
p
elli
n
g
er
r
o
r
s
o
f
th
e
w
r
iti
n
g
.
P
ar
ticip
an
ts
w
er
e
r
eq
u
ir
ed
to
p
er
f
o
r
m
t
h
e
ex
p
r
ess
i
v
e
w
r
i
tin
g
in
ter
v
e
n
tio
n
f
o
r
ar
o
u
n
d
1
5
-
2
0
m
in
u
te
s
o
n
th
e
o
n
li
n
e
w
o
r
k
s
h
ee
t
g
e
n
er
ated
f
r
o
m
t
h
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9
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18
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d
in
th
e
f
i
n
al
s
a
m
p
le
b
ec
au
s
e
t
h
er
e
w
er
e
t
w
o
p
ar
ticip
an
ts
w
h
o
w
it
h
d
r
e
w
f
r
o
m
t
h
e
s
t
u
d
y
d
u
e
to
ab
s
en
te
eis
m
o
f
o
n
e
o
f
t
h
e
w
r
i
tin
g
s
ess
io
n
s
.
P
u
r
p
o
s
iv
e
s
a
m
p
li
n
g
w
as
u
t
ilized
i
n
o
r
d
er
to
r
ec
r
u
it
th
e
m
,
w
h
er
e
t
h
e
o
p
p
o
r
tu
n
it
y
to
p
ar
ticip
ate
w
a
s
ad
v
er
ti
s
ed
to
u
n
d
er
g
r
ad
u
ates
o
f
th
e
p
r
iv
ate
u
n
i
v
er
s
i
t
y
o
n
t
h
e
s
o
cial
m
ed
ia
p
latf
o
r
m
s
u
c
h
as
th
r
o
u
g
h
th
e
p
r
iv
ate
u
n
i
v
er
s
i
t
y
’
s
in
ta
k
e
g
r
o
u
p
s
in
Face
b
o
o
k
an
d
W
h
ats
A
p
p
.
T
h
e
p
ar
ticip
an
ts
w
er
e
g
u
id
ed
to
lo
g
o
n
to
th
e
ir
p
o
r
tal
ac
co
u
n
t
an
d
s
ig
n
u
p
f
o
r
th
e
r
esear
ch
e
x
p
er
im
en
t
in
t
h
e
p
o
r
tal.
A
s
cr
ee
n
in
g
test
w
o
u
ld
b
e
p
r
o
v
id
ed
to
th
e
p
ar
ticip
an
ts
p
r
io
r
to
o
n
lin
e
ex
p
er
i
m
en
t
s
e
s
s
io
n
,
to
ch
ec
k
i
f
p
ar
ticip
an
ts
d
id
f
u
l
f
ill
th
e
cr
i
ter
ia
o
f
(
a)
Sh
o
u
l
d
n
o
t
b
e
d
iag
n
o
s
ed
w
it
h
an
y
s
ev
er
e
p
s
y
c
h
o
lo
g
i
ca
l
d
is
o
r
d
er
s
;
(
b
)
Mu
s
t
n
o
t
cu
r
r
en
tl
y
p
ar
ticip
ate
i
n
a
n
y
co
u
n
s
eli
n
g
o
r
p
s
y
ch
o
t
h
er
a
p
y
s
es
s
io
n
s
;
(
c)
H
av
e
b
ee
n
e
x
p
o
s
ed
to
a
tr
a
u
m
a
tic
o
r
s
tr
ess
f
u
l
e
x
p
er
ien
ce
m
o
r
e
th
an
o
n
e
m
o
n
th
ag
o
.
T
h
e
s
t
u
d
y
w
as
ap
p
r
o
v
ed
b
y
t
h
e
u
n
i
v
er
s
i
t
y
’
s
et
h
ical
r
e
v
ie
w
b
o
ar
d
.
E
ac
h
p
ar
ticip
an
t
r
e
ce
iv
ed
a
0
.
7
5
%
o
f
co
u
r
s
e
ex
tr
a
cr
ed
its
as
co
m
p
en
s
atio
n
i
n
t
h
eir
s
e
m
es
ter
f
o
r
co
m
p
letin
g
t
h
r
ee
s
e
s
s
io
n
s
o
f
th
e
o
n
lin
e
w
r
iti
n
g
in
ter
v
e
n
tio
n
.
2
.
4
.
P
r
o
ce
du
re
Af
ter
co
m
p
letio
n
o
f
t
h
e
s
cr
ee
n
in
g
te
s
t,
p
ar
ticip
an
ts
w
er
e
a
s
s
ig
n
ed
w
it
h
o
n
e
o
f
t
h
e
co
n
d
iti
o
n
s
,
w
h
ich
w
er
e
P
E
W
(
n
=
3
1
)
,
NE
W
(
n
=
3
2
)
an
d
C
W
(
n
=
2
3
)
co
n
d
itio
n
s
.
A
t
th
e
b
e
g
i
n
n
i
n
g
o
f
th
e
s
tu
d
y
,
p
ar
ticip
an
t
s
r
ec
eiv
ed
a
lin
k
to
ac
ce
s
s
Go
o
g
le
Fo
r
m
f
o
r
th
e
f
ir
s
t
s
e
s
s
i
o
n
o
f
t
h
e
s
t
u
d
y
th
r
o
u
g
h
t
h
ei
r
e
m
ails
th
at
w
er
e
r
eg
is
ter
ed
u
n
d
er
t
h
eir
I
P
SY
p
r
o
f
iles
.
All
p
ar
ticip
an
t
s
w
er
e
r
eq
u
ir
ed
to
co
m
p
lete
t
h
e
s
t
u
d
y
b
y
u
s
i
n
g
th
eir
o
w
n
elec
tr
o
n
ic
g
ad
g
et
w
i
th
i
n
2
4
h
o
u
r
s
.
A
t
t
h
e
f
ir
s
t
p
ag
e
o
f
t
h
e
f
o
r
m
,
p
ar
ticip
an
t
s
w
er
e
g
iv
e
n
a
n
in
f
o
r
m
ed
co
n
s
e
n
t
ab
o
u
t
th
e
p
u
r
p
o
s
e
an
d
n
at
u
r
e
o
f
th
e
s
t
u
d
y
.
T
h
e
y
w
er
e
ab
le
t
o
in
d
icate
th
e
ir
v
o
l
u
n
tar
y
p
ar
t
icip
atio
n
at
t
h
e
e
n
d
o
f
th
e
f
ir
s
t
p
ag
e.
Nex
t,
th
e
y
c
o
m
p
leted
t
h
e
d
e
m
o
g
r
ap
h
ic
q
u
esti
o
n
n
air
e,
f
o
llo
w
ed
b
y
t
h
e
p
r
etr
ea
t
m
en
t
m
ea
s
u
r
e
o
f
B
DI
an
d
p
r
e
w
r
iti
n
g
m
ea
s
u
r
e
o
f
P
A
N
AS.
Af
ter
co
m
p
let
in
g
th
e
q
u
est
io
n
n
air
es,
t
h
e
y
t
h
en
p
er
f
o
r
m
ed
th
e
w
r
iti
n
g
in
ter
v
en
t
io
n
b
y
t
y
p
i
n
g
th
e
co
n
te
n
t
in
t
h
e
s
p
ac
e
p
r
o
v
id
ed
b
elo
w
th
e
r
esp
ec
ti
v
e
in
s
tr
u
ctio
n
s
o
f
th
eir
co
n
d
itio
n
s
.
T
h
er
e
w
er
e
n
o
r
est
r
ictio
n
s
o
n
t
h
e
w
o
r
d
li
m
it
f
o
r
th
e
le
n
g
th
o
f
th
eir
w
r
iti
n
g
.
I
n
th
e
n
ex
t
p
ag
e,
th
e
y
f
illed
i
n
a
p
o
s
t
-
w
r
iti
n
g
ass
e
s
s
m
en
t
o
f
P
A
N
AS.
L
a
s
tl
y
,
th
e
y
m
a
y
clic
k
o
n
t
h
e
“
S
u
b
m
it”
b
u
tt
o
n
to
r
ec
o
r
d
th
eir
r
esp
o
n
s
es
f
o
r
th
e
f
ir
s
t ses
s
io
n
.
T
h
e
lin
k
s
f
o
r
t
h
e
s
ec
o
n
d
s
es
s
i
o
n
w
er
e
s
en
t
to
p
ar
ticip
an
t
s
v
ia
e
m
a
il
o
n
e
w
ee
k
a
f
ter
t
h
e
y
co
m
p
leted
th
e
f
ir
s
t
s
es
s
io
n
.
I
n
th
e
s
ec
o
n
d
s
ess
io
n
,
p
ar
ticip
an
t
s
w
er
e
r
eq
u
ir
ed
to
p
er
f
o
r
m
th
e
s
a
m
e
w
r
i
tin
g
co
n
d
itio
n
w
it
h
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p
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feelin
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s
w
ith
ex
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ive
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C
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n
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437
th
e
m
ea
s
u
r
e
m
en
t
o
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p
r
e
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n
d
p
o
s
t
-
w
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tin
g
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A
N
AS.
O
n
e
w
ee
k
a
f
ter
t
h
e
s
ec
o
n
d
s
ess
io
n
,
t
h
e
lin
k
s
to
ac
ce
s
s
t
h
e
th
ir
d
w
r
it
in
g
s
e
s
s
io
n
w
er
e
s
e
n
t
to
p
ar
ticip
an
ts
v
ia
e
m
a
il.
I
n
th
e
th
ir
d
s
ess
io
n
,
s
a
m
e
w
r
it
in
g
in
s
tr
u
ct
io
n
s
w
er
e
ap
p
lied
to
th
e
p
ar
ticip
an
t
s
o
f
r
esp
ec
tiv
e
co
n
d
it
io
n
s
w
h
ile
t
h
er
e
w
er
e
al
s
o
p
r
e
-
a
n
d
p
o
s
t
-
w
r
iti
n
g
as
s
es
s
m
en
t
s
o
f
P
A
N
AS.
Up
o
n
co
m
p
leti
n
g
th
e
last
s
ess
io
n
o
f
w
r
iti
n
g
,
th
e
p
o
s
t
-
tr
ea
t
m
e
n
t
B
DI
q
u
est
io
n
n
air
e
w
a
s
f
i
lled
i
n
b
y
p
ar
ticip
an
ts
.
A
ll p
ar
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an
t
s
w
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e
t
h
a
n
k
ed
f
o
r
t
h
eir
p
ar
ticip
atio
n
at
th
e
e
n
d
o
f
th
e
Go
o
g
l
e
Fo
r
m
.
3.
RE
SU
L
T
S
A
ND
D
I
SCU
SS
I
O
N
3
.
1
.
B
a
s
eline
d
a
t
a
B
aselin
e
co
m
p
ar
is
o
n
s
a
m
o
n
g
th
r
ee
w
r
i
tin
g
g
r
o
u
p
s
w
er
e
tak
en
o
n
th
e
m
ea
s
u
r
e
o
f
B
DI
an
d
P
A
NAS
.
A
s
er
ies
o
f
o
n
e
-
w
a
y
A
N
OV
As
s
h
o
w
ed
t
h
at
t
h
er
e
w
er
e
n
o
s
i
g
n
i
f
ica
n
t
d
i
f
f
er
e
n
ce
s
i
n
d
ep
r
es
s
iv
e
s
y
m
p
to
m
s
a
n
d
n
eg
at
iv
e
a
f
f
ec
t
b
et
w
ee
n
P
E
W
,
NE
W
an
d
C
W
g
r
o
u
p
s
(
ps
>
.
0
5
)
at
b
aselin
e.
Ho
w
e
v
er
,
th
er
e
w
a
s
a
s
ig
n
i
f
ica
n
t
d
if
f
er
e
n
ce
in
p
o
s
iti
v
e
af
f
ec
t
b
et
w
ee
n
P
E
W
,
NE
W
an
d
C
W
g
r
o
u
p
s
,
F
(
2
,
8
3
)
=
5
.
4
2
,
p
=
.
0
0
6
.
Po
s
t
h
o
c
an
al
y
s
i
s
u
s
i
n
g
T
u
k
e
y
HSD
s
h
o
w
ed
th
at
th
e
p
o
s
itiv
e
af
f
ec
t
i
n
Gr
o
u
p
PEW
is
s
ig
n
i
f
ican
tl
y
lo
w
er
th
an
Gr
o
u
p
NE
W
(
M
diff
=
-
5
.
4
0
,
S
E
=
1
.
8
4
,
p
=
.
0
1
2
)
an
d
Gr
o
u
p
C
W
(
M
diff
=
-
5
.
4
3
,
S
E
=
2
.
0
1
,
p
=
.
0
2
3
)
at
b
asel
in
e.
T
ab
le
1
in
d
icate
s
th
e
m
u
ltip
le
co
m
p
ar
is
o
n
s
o
f
p
o
s
iti
v
e
a
f
f
ec
t
b
et
w
ee
n
Gr
o
u
p
P
E
W
,
NE
W
an
d
C
W
a
t
b
aselin
e.
T
h
u
s
,
a
t
w
o
-
w
a
y
ANOV
A
w
o
u
ld
b
e
co
n
d
u
cted
t
o
ch
ec
k
w
h
et
h
er
t
h
e
d
i
f
f
er
e
n
c
e
in
b
asel
in
e
s
co
r
es
w
o
u
ld
af
f
ec
t
t
h
e
m
a
n
ip
u
la
tio
n
o
f
th
e
in
te
n
d
ed
p
o
s
itiv
e
af
f
ec
t
in
w
r
i
tin
g
g
r
o
u
p
s
,
w
h
ile
T
ab
le
2
s
h
o
w
s
t
h
e
co
m
p
lete
m
ea
n
s
co
r
es o
f
t
h
e
v
ar
iab
les in
th
e
b
ase
lin
e.
T
ab
le
1
.
T
u
r
k
e
y
HSD
co
m
p
ar
i
s
o
n
s
f
o
r
p
o
s
itiv
e
a
f
f
ec
t a
t b
ase
lin
e
C
o
mp
a
r
i
so
n
s
M
d
i
f
f
SE
p
P
EW
v
s.
N
EW
-
5
.
4
0
1
.
8
4
.
0
1
2
P
EW
v
s.
C
W
-
5
.
4
3
2
.
0
1
.
0
2
3
N
EW
v
s.
C
W
-
0
.
3
3
2
.
0
0
1
.
0
0
0
T
ab
le
2
.
B
aselin
e
m
ea
n
s
co
r
es
o
f
B
DI
,
P
A
NAS
(
p
o
s
itiv
e)
an
d
P
A
NAS
(
n
e
g
ati
v
e)
b
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440
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4
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[
1
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]
.
I
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t
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[
4
7
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.
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8
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.
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2
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h
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en
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t
h
e
f
ac
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f
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y
[
4
8
]
.
Hen
ce
,
th
e
in
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s
e
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n
co
p
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r
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id
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w
h
o
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v
u
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er
ab
le
to
s
tr
ess
[
4
9
]
.
A
s
a
n
illu
s
tr
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n
,
in
d
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v
id
u
a
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w
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[
2
7
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,
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u
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y
ch
o
lo
g
ical
b
en
e
f
it
s
th
r
o
u
g
h
cr
ea
ti
n
g
p
o
s
itiv
e
u
p
war
d
s
p
ir
als
f
o
r
e
m
o
tio
n
al
w
ell
-
b
ein
g
[
3
2
]
as
th
e
ef
f
ec
t
s
o
f
t
h
e
p
o
s
itiv
e
e
m
o
tio
n
s
w
il
l a
cc
u
m
u
late
t
h
r
o
u
g
h
co
n
ti
n
u
o
u
s
p
r
ac
tice
o
f
t
h
e
w
r
i
tin
g
f
o
r
th
r
ee
s
ess
io
n
s
i
n
th
i
s
s
t
u
d
y
.
A
lt
h
o
u
g
h
P
E
W
co
n
d
itio
n
d
id
n
o
t
in
d
u
ce
s
i
g
n
i
f
ican
tl
y
h
ig
h
e
r
p
o
s
itiv
e
af
f
ec
t
t
h
an
C
W
co
n
d
itio
n
af
ter
w
r
iti
n
g
,
th
e
r
e
s
u
l
ts
o
f
p
o
s
t
-
tr
ea
t
m
e
n
t
s
h
o
w
ed
th
at
P
E
W
w
as
s
till
s
u
p
er
io
r
to
C
W
in
r
ed
u
cin
g
d
ep
r
ess
i
v
e
s
y
m
p
to
m
s
.
T
h
is
s
u
g
g
ested
t
h
at
ev
e
n
t
h
o
u
g
h
p
o
s
it
iv
e
a
f
f
ec
t
is
n
ec
e
s
s
ar
y
f
o
r
b
r
o
ad
en
in
g
o
f
th
o
u
g
h
t
a
n
d
b
u
ild
in
g
o
f
p
er
s
o
n
al
r
eso
u
r
c
es,
th
e
af
f
ec
t
m
i
g
h
t
n
o
t
b
e
th
e
o
n
l
y
co
n
tr
ib
u
t
in
g
f
ac
to
r
f
o
r
in
d
iv
id
u
als
to
ex
p
er
ien
ce
co
g
n
iti
v
e
b
r
o
ad
en
in
g
a
n
d
g
ain
p
s
y
ch
o
lo
g
ical
b
en
ef
its
f
r
o
m
t
h
e
p
r
o
ce
s
s
.
Stu
d
y
[
5
0
]
m
en
tio
n
ed
th
at
o
n
e’
s
u
s
e
o
f
g
lo
b
al
o
r
lo
ca
l
f
o
cu
s
m
i
g
h
t
b
e
a
m
ed
iatin
g
f
ac
t
o
r
in
th
e
b
r
o
ad
en
a
n
d
b
u
ild
m
o
d
el.
Fo
r
in
s
tan
ce
,
in
d
iv
id
u
als
w
h
o
e
n
g
a
g
e
in
C
W
co
n
d
itio
n
m
ig
h
t
b
e
less
lik
el
y
to
ad
o
p
t
a
g
lo
b
al
f
o
cu
s
as
co
m
p
ar
ed
to
P
E
W
co
n
d
itio
n
b
ec
a
u
s
e
th
e
co
n
tr
o
l
w
r
iti
n
g
i
n
s
tr
u
ctio
n
s
w
er
e
e
m
p
h
asized
o
n
r
eiter
ati
n
g
d
ail
y
r
o
u
tin
e
as
o
b
j
ec
tiv
e
an
d
d
etailed
as
p
o
s
s
ib
le.
I
t
was
u
n
li
k
el
y
t
h
at
i
n
d
iv
id
u
a
ls
wo
u
ld
ex
p
lo
r
e
t
h
eir
d
ail
y
e
x
p
er
ien
ce
f
r
o
m
a
w
id
er
p
er
s
p
ec
tiv
e
o
r
d
is
co
v
er
n
e
w
m
ea
n
in
g
s
th
r
o
u
g
h
o
b
j
ec
tiv
el
y
wr
itin
g
ab
o
u
t th
eir
d
ail
y
r
o
u
ti
n
e
[
4
]
.
T
h
er
ef
o
r
e,
th
e
co
g
n
iti
v
e
b
r
o
ad
en
i
n
g
m
ig
h
t
n
o
t
o
cc
u
r
w
it
h
o
u
t
th
e
p
r
esen
ce
o
f
g
lo
b
al
f
o
cu
s
i
n
th
e
w
r
iti
n
g
in
ter
v
e
n
tio
n
,
w
h
ic
h
s
u
b
s
eq
u
en
t
l
y
w
o
u
ld
n
o
t
lead
to
th
e
b
u
ild
in
g
o
r
ac
cu
m
u
lat
io
n
o
f
p
er
s
o
n
al
co
p
in
g
r
eso
u
r
ce
s
th
at
i
s
cr
u
cial
i
n
r
ed
u
cin
g
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
.
I
n
ad
d
itio
n
,
th
is
s
t
u
d
y
al
s
o
f
o
u
n
d
o
u
t
t
h
at
th
e
f
o
u
r
t
h
h
y
p
o
t
h
esi
s
w
as
n
o
t
s
u
p
p
o
r
ted
s
in
ce
NE
W
d
id
n
o
t
r
ep
o
r
t
a
s
ig
n
i
f
ica
n
t
g
r
ea
ter
r
ed
u
ctio
n
in
d
ep
r
ess
i
v
e
s
y
m
p
t
o
m
s
as
co
m
p
ar
ed
to
C
W
co
n
d
itio
n
.
T
h
e
f
in
d
i
n
g
s
co
n
tr
ad
icted
th
e
p
r
ev
io
u
s
l
iter
atu
r
e
[
1
1
]
,
[
13
]
,
[
47
]
th
at
h
ig
h
li
g
h
ted
t
h
e
e
f
f
icac
y
o
f
NE
W
o
r
tr
au
m
a
-
f
o
cu
s
e
d
ex
p
r
ess
i
v
e
w
r
iti
n
g
o
n
r
ed
u
ci
n
g
p
s
y
c
h
o
lo
g
ical
s
y
m
p
to
m
s
in
b
o
th
cli
n
ical
an
d
n
o
n
-
cli
n
ical
p
o
p
u
latio
n
s
as
co
m
p
ar
ed
to
co
n
tr
o
l
w
r
iti
n
g
c
o
n
d
itio
n
.
O
n
e
ex
p
la
n
atio
n
m
i
g
h
t
b
e
th
e
n
eg
a
tiv
e
a
f
f
ec
t
t
h
at
w
a
s
in
d
u
ce
d
d
u
r
in
g
NE
W
co
n
d
itio
n
w
o
u
ld
n
ar
r
o
w
i
n
d
iv
id
u
als
’
th
o
u
g
h
t
-
ac
tio
n
r
ep
er
to
i
r
e
an
d
cr
ea
te
a
lo
ca
l
f
o
cu
s
ap
p
r
o
ac
h
in
m
ak
in
g
s
e
n
s
e
o
f
t
h
eir
ex
p
er
ien
ce
d
u
r
in
g
th
e
s
tr
u
ct
u
r
ed
w
r
i
tin
g
[
2
8
]
.
W
h
en
th
e
t
h
o
u
g
h
t
-
ac
tio
n
r
ep
er
to
ir
e
is
n
ar
r
o
w
ed
,
in
d
i
v
id
u
al
s
w
ill
h
av
e
f
e
w
er
o
p
tio
n
s
an
d
r
eso
u
r
ce
s
to
co
p
e
w
it
h
t
h
eir
s
tr
ess
f
u
l
li
f
e
ev
e
n
t
s
,
ev
en
t
u
all
y
t
h
e
le
v
el
o
f
d
ep
r
ess
i
v
e
s
y
m
p
to
m
s
w
ill
n
o
t
b
e
r
ed
u
ce
d
.
No
tab
ly
,
Mo
b
er
l
y
an
d
W
atk
i
n
s
[
5
1
]
m
en
tio
n
ed
t
h
e
n
eg
at
iv
e
a
f
f
ec
t
is
o
f
te
n
a
s
s
o
ciate
d
w
it
h
t
h
e
en
g
a
g
e
m
en
t
i
n
r
u
m
i
n
ati
v
e
s
el
f
-
f
o
c
u
s
.
T
h
u
s
,
th
e
ten
d
en
c
y
to
r
u
m
in
a
te
w
il
l
p
er
p
etu
ate
n
eg
at
iv
e
th
in
k
i
n
g
p
att
er
n
s
a
n
d
r
ed
u
ce
o
n
e’
s
ab
ili
t
y
to
co
p
e
w
it
h
th
eir
ad
v
er
s
e
p
ast ex
p
er
ien
ce
[
5
2
]
,
h
en
ce
t
h
e
s
y
m
p
to
m
s
r
ed
u
c
tio
n
m
ig
h
t
n
o
t b
e
ef
f
ec
tiv
e
t
h
r
o
u
g
h
NE
W
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
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.
P
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Hea
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Sci.
I
SS
N:
2
2
5
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(
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441
T
h
e
last
h
y
p
o
th
e
s
is
w
as
n
o
t
s
u
p
p
o
r
ted
as
p
ar
ticip
an
ts
i
n
P
E
W
co
n
d
itio
n
d
id
n
o
t
r
ep
o
r
t
s
i
g
n
i
f
ica
n
tl
y
lo
w
er
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ep
r
ess
i
v
e
s
y
m
p
to
m
s
a
s
co
m
p
ar
ed
to
NE
W
co
n
d
itio
n
at
p
o
s
t
-
tr
ea
t
m
e
nt
.
T
h
is
f
i
n
d
i
n
g
i
s
n
o
t
co
n
s
i
s
te
n
t
w
it
h
th
e
th
eo
r
etica
l
m
o
d
el
t
h
at
ex
tr
ap
o
lated
th
e
P
E
W
w
o
u
ld
lead
to
g
r
ea
ter
r
ed
u
ctio
n
i
n
d
e
p
r
ess
iv
e
s
y
m
p
to
m
s
as
co
m
p
ar
ed
to
NE
W
[
3
1
]
.
On
e
o
f
t
h
e
e
x
p
lan
a
tio
n
s
m
i
g
h
t
b
e
w
h
ile
t
h
e
n
eg
a
tiv
e
a
f
f
e
ct
th
a
t
w
a
s
i
n
d
u
ce
d
d
u
r
in
g
NE
W
w
ill
lead
to
a
s
elf
-
f
o
cu
s
a
n
d
s
el
f
-
r
u
m
i
n
ati
n
g
te
n
d
en
c
y
;
t
h
e
r
ep
ea
ted
ex
p
o
s
u
r
e
o
f
NE
W
to
in
d
iv
id
u
als
m
i
g
h
t
ac
tu
all
y
p
r
o
d
u
ce
a
h
ab
itu
atio
n
f
o
r
th
es
e
n
eg
ati
v
e
e
m
o
t
io
n
al
r
esp
o
n
s
es
as
s
tated
in
t
h
e
ex
p
o
s
u
r
e
h
y
p
o
th
e
s
is
[
5
3
]
.
A
s
an
ill
u
s
tr
atio
n
,
in
d
i
v
id
u
al
s
w
o
u
ld
h
a
v
e
less
i
n
te
n
s
e
n
e
g
ati
v
e
ar
o
u
s
al
w
h
e
n
th
e
y
w
r
o
te
ab
o
u
t
th
eir
p
ast
s
tr
e
s
s
f
u
l
o
r
tr
au
m
a
tic
ex
p
er
ien
ce
f
o
r
th
e
s
ec
o
n
d
o
r
th
ir
d
ti
m
e
[
1
8
]
a
n
d
th
e
ten
d
e
n
c
y
t
o
r
u
m
i
n
ate
m
i
g
h
t
b
e
r
ed
u
ce
d
a
s
w
ell.
Hen
ce
,
t
h
i
s
m
i
g
h
t
ex
p
lain
t
h
e
d
ep
r
ess
i
v
e
s
y
m
p
to
m
s
o
f
NE
W
d
id
n
o
t
d
if
f
er
s
i
g
n
i
f
ica
n
tl
y
w
i
th
P
E
W
at
p
o
s
t
-
tr
ea
t
m
en
t,
s
i
n
ce
t
h
e
n
eg
at
iv
e
r
e
s
p
o
n
s
es
o
f
N
E
W
m
ig
h
t
d
i
m
i
n
i
s
h
th
r
o
u
g
h
r
ep
ea
ted
p
r
ac
tice.
An
o
th
er
ex
p
la
n
atio
n
m
i
g
h
t
b
e
th
e
in
d
u
c
ed
n
e
g
ati
v
e
af
f
ec
t
d
u
r
in
g
NE
W
w
ill
ac
t
u
all
y
lead
to
a
n
in
-
d
ep
th
an
al
y
s
is
o
f
p
er
s
o
n
al
e
x
p
er
ien
ce
;
h
en
ce
i
n
d
iv
id
u
als
wo
u
ld
b
e
ab
le
t
o
g
ain
m
o
r
e
in
s
ig
h
ts
i
n
to
th
eir
p
ast
ex
p
er
ien
ce
an
d
in
te
g
r
ate
th
eir
n
eg
ati
v
e
ex
p
er
ien
ce
[
19
]
,
[
24
]
.
T
h
is
ex
p
lan
atio
n
h
ig
h
li
g
h
t
ed
th
at
p
er
h
ap
s
th
e
p
o
s
itiv
e
a
n
d
n
eg
a
tiv
e
af
f
ec
t
p
lay
s
a
d
if
f
er
en
t
r
o
le
f
o
r
in
d
iv
id
u
al
s
to
p
r
o
ce
s
s
t
h
eir
e
x
p
er
ien
ce
d
u
r
i
n
g
t
h
e
w
r
iti
n
g
s
e
s
s
io
n
s
.
Fo
r
i
n
s
ta
n
ce
,
p
o
s
itiv
e
a
f
f
ec
t
elicited
d
u
r
i
n
g
P
E
W
m
ig
h
t
lead
to
co
g
n
i
ti
v
e
b
r
o
ad
en
in
g
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t th
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all
s
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ize
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icip
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n
ts
.
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h
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s
t
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y
h
a
d
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ited
8
6
u
n
d
er
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ates
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o
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g
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th
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ex
p
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Ma
la
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b
u
t
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s
till
d
id
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o
t
r
ea
ch
th
e
i
n
itial r
eq
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ir
e
m
e
n
t o
f
1
2
0
p
ar
ticip
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ts
to
m
ee
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p
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f
0
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8
0
an
d
th
e
ef
f
ec
t si
ze
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f
f
=
0
.
2
5
[
5
4
]
in
o
r
d
er
to
s
u
f
f
ic
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tl
y
d
etec
t
t
h
e
ef
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h
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th
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d
ata
co
llect
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m
aj
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ize
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ch
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au
s
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all
o
f
th
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p
ar
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ts
in
t
h
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y
w
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r
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r
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ited
f
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m
th
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a
m
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m
aj
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p
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iv
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it
y
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d
th
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lac
k
o
f
d
iv
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i
t
y
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th
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s
u
b
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t
p
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o
ls
m
ig
h
t
lead
to
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n
r
ep
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tati
v
en
e
s
s
o
f
t
h
e
p
o
p
u
latio
n
at
lar
g
e
[
5
5
]
.
Hen
ce
,
b
y
r
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r
u
itin
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t
s
f
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lectio
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ac
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n
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li
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s
t
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d
y
[
3
4
]
.
T
h
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m
aj
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th
at
ca
u
s
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lack
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tech
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ical
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p
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ex
p
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m
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n
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tal
f
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n
th
i
s
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t
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y
,
all
p
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w
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r
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f
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o
m
t
h
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m
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ex
p
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m
e
n
tal
p
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tal
th
at
w
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s
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in
t
h
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u
n
i
v
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t
y
.
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h
e
y
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w
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to
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ig
n
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p
f
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lo
ts
th
at
t
h
e
y
w
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ted
in
th
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t
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.
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ce
,
th
e
allo
ca
tio
n
o
f
tr
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t
m
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itio
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as
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p
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Fo
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ta
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f
1
A
s
lo
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ca
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W
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p
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p
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t
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o
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ab
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p
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f
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th
at
w
a
s
d
escr
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b
ed
in
a
s
tu
d
y
[
5
6
]
,
in
w
h
ich
t
h
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w
ill
b
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a
lis
t
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f
r
an
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tio
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co
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t
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th
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co
m
p
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p
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to
th
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llectio
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p
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ase.
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t
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ar
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u
p
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ex
p
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m
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n
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cr
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test
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ch
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to
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r
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t
m
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co
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to
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p
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s
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h
o
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in
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s
,
th
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in
d
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p
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ati
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af
f
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t
d
id
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ex
p
lain
th
e
e
f
f
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o
f
b
o
th
P
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W
an
d
NE
W
as
co
m
p
ar
ed
to
C
W
in
t
h
e
w
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iti
n
g
s
ess
io
n
s
.
T
h
er
ef
o
r
e,
it
is
cr
u
cial
to
in
v
esti
g
ate
t
h
e
u
n
d
er
l
y
in
g
p
s
y
ch
o
lo
g
ical
m
ec
h
a
n
i
s
m
o
f
d
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r
ea
s
ed
p
s
y
ch
o
lo
g
ical
s
y
m
p
to
m
s
o
f
P
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W
b
ec
au
s
e
th
is
w
il
l
ass
i
s
t
th
er
ap
is
ts
o
r
in
ter
v
e
n
tio
n
i
s
ts
to
d
eter
m
in
e
w
h
et
h
er
th
is
i
n
ter
v
en
t
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n
is
s
u
i
tab
le
f
o
r
th
e
u
s
e
o
f
p
u
b
lic
as
w
el
l a
s
f
o
r
in
d
iv
id
u
a
ls
w
it
h
p
s
y
ch
o
lo
g
ic
al
co
n
d
itio
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s
.
T
h
is
r
esear
ch
h
as c
o
m
p
a
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th
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ef
f
ec
ti
v
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s
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o
f
w
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g
ab
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t p
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p
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itiv
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p
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c
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p
er
s
o
n
al
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eg
at
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x
p
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ce
a
s
w
ell
as
d
ail
y
r
o
u
ti
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(
co
n
tr
o
l
t
o
p
ic)
in
r
ed
u
cin
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d
ep
r
ess
iv
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s
y
m
p
to
m
s
a
m
o
n
g
u
n
d
er
g
r
ad
u
ates.
W
h
ile
p
ast
s
tu
d
ie
s
h
av
e
m
ai
n
l
y
e
m
p
h
a
s
ized
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ex
p
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v
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g
o
f
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au
m
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ex
p
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,
t
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t
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y
i
n
tr
o
d
u
ce
d
B
u
r
to
n
an
d
Ki
n
g
’
s
[
1
9
]
in
s
tr
u
ctio
n
o
f
p
o
s
iti
v
e
ex
p
er
ie
n
ce
w
r
iti
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g
in
to
t
h
e
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n
lin
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x
p
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i
m
e
n
tal
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tin
g
.
B
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s
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b
r
o
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en
an
d
b
u
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m
o
d
el
s
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th
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t
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l
f
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m
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w
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k
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t
h
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s
t
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y
f
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d
o
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th
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t
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a
f
f
ec
t
m
i
g
h
t
p
la
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a
n
i
m
p
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r
ta
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t
r
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r
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i
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d
iv
id
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d
ep
r
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i
v
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s
b
y
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r
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en
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g
co
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b
u
ild
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co
p
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r
eso
u
r
ce
s
an
d
cu
lt
iv
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g
r
esil
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ce
.
Ho
w
ev
er
,
th
er
e
m
i
g
h
t
b
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t
h
er
p
o
ten
tial
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g
f
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to
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s
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s
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s
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tio
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p
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to
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d
r
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f
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t
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r
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r
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ch
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T
h
is
s
tu
d
y
h
as
also
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x
te
n
d
ed
t
h
e
r
o
le
o
f
b
r
o
ad
en
a
n
d
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N:
2
2
5
2
-
8
8
0
6
I
n
t.
J
.
P
u
b
lic
Hea
lth
Sci.,
Vo
l.
1
0
,
No
.
2
,
J
u
n
e
20
21
:
4
33
–
4
44
442
b
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f
r
a
m
e
wo
r
k
th
at
ca
n
h
elp
to
r
ed
u
ce
s
y
m
p
to
m
s
o
f
d
ep
r
ess
io
n
f
o
r
th
o
s
e
w
h
o
ar
e
v
u
ln
er
ab
le
to
s
tr
ess
th
r
o
u
g
h
e
m
o
tio
n
al
d
i
s
clo
s
u
r
e
w
r
iti
n
g
.
Fu
r
t
h
er
m
o
r
e,
th
e
f
i
n
d
i
n
g
s
o
f
t
h
is
r
esear
ch
h
av
e
p
r
o
v
id
ed
s
o
m
e
p
r
eli
m
i
n
ar
y
i
n
s
i
g
h
ts
i
n
to
th
e
p
o
ten
tial
v
al
u
e
o
f
t
h
e
o
n
li
n
e
p
r
ac
tice
o
f
w
r
i
tin
g
ab
o
u
t
p
er
s
o
n
al
p
o
s
itiv
e
ex
p
er
ien
ce
i
n
r
ed
u
cin
g
d
e
p
r
ess
iv
e
s
y
m
p
to
m
s
a
m
o
n
g
u
n
d
er
g
r
ad
u
ates.
T
h
e
t
h
eo
r
etica
l
m
ec
h
a
n
i
s
m
o
f
w
r
iti
n
g
ab
o
u
t
p
o
s
iti
v
e
e
m
o
tio
n
al
e
x
p
er
ien
ce
i
s
s
i
m
ilar
to
th
e
p
o
s
itiv
e
p
s
y
c
h
o
lo
g
y
tec
h
n
iq
u
e
s
u
ch
as
t
h
e
p
r
o
ce
s
s
o
f
s
av
o
r
in
g
an
d
r
e
m
i
n
i
s
ce
n
ce
[
5
7
]
,
w
h
ile
t
h
e
w
r
i
tin
g
p
r
o
ce
s
s
is
m
o
r
e
s
tr
u
ct
u
r
ed
an
d
in
s
i
g
h
tf
u
l
f
o
r
i
n
d
iv
id
u
als
to
p
r
ac
tice
[
1
8
]
.
Hen
ce
,
th
e
ed
u
ca
tio
n
al
s
ec
to
r
ca
n
in
tr
o
d
u
ce
th
e
p
o
s
itiv
e
e
x
p
er
ien
ce
w
r
it
in
g
p
r
ac
tice
in
to
u
n
i
v
er
s
it
y
s
ett
in
g
s
,
g
u
id
i
n
g
i
n
d
iv
i
d
u
als
to
w
r
ite
ab
o
u
t
th
eir
o
w
n
p
o
s
itiv
e
e
x
p
er
ien
ce
in
th
e
o
n
l
in
e
p
lat
f
o
r
m
s
u
ch
as
p
er
s
o
n
al
s
o
cial
m
ed
ia
ac
co
u
n
ts
to
h
elp
allev
iate
th
e
n
eg
at
iv
e
s
y
m
p
to
m
s
t
h
at
m
ig
h
t
ar
is
e
f
r
o
m
o
n
e’
s
s
tr
e
s
s
f
u
l
lif
es
t
y
le.
T
h
i
s
w
r
iti
n
g
tech
n
iq
u
e
m
ig
h
t
al
s
o
s
er
v
e
as
an
e
f
f
ec
ti
v
e
co
p
in
g
s
tr
ate
g
y
f
o
r
i
n
d
iv
id
u
als
w
h
o
ar
e
v
u
l
n
er
ab
le
to
s
tr
ess
a
n
d
an
x
iet
y
,
s
u
c
h
as
p
eo
p
le
w
h
o
ex
p
er
ien
ce
d
lo
s
s
o
f
e
m
p
lo
y
m
en
t
d
u
r
i
n
g
C
O
VI
D
-
1
9
p
an
d
em
ic.
F
u
r
th
er
m
o
r
e,
e
v
e
n
t
h
o
u
g
h
tr
au
m
a
-
f
o
cu
s
ed
w
r
iti
n
g
h
as
b
ee
n
u
s
ed
p
r
i
m
ar
il
y
i
n
n
ar
r
ativ
e
a
n
d
ex
p
o
s
u
r
e
th
er
ap
y
[
1
5
]
,
[
1
4
]
,
th
er
ap
is
ts
o
r
in
ter
v
e
n
tio
n
is
t
s
co
u
ld
in
tr
o
d
u
ce
a
n
alter
n
ati
v
e
o
f
p
o
s
iti
v
e
ex
p
er
ie
n
ce
w
r
iti
n
g
as
a
m
o
r
e
s
tr
e
n
g
t
h
-
f
o
cu
s
ed
te
ch
n
iq
u
e
f
o
r
clien
ts
w
h
o
ar
e
u
n
co
m
f
o
r
tab
le
to
ex
p
lo
r
e
th
eir
tr
au
m
atic
o
r
s
tr
es
s
f
u
l
p
ast
e
x
p
er
ien
ce
t
h
r
o
u
g
h
tr
ad
itio
n
al
ex
p
r
es
s
i
v
e
w
r
iti
n
g
.
4.
CO
NCLU
SI
O
N
A
ll
i
n
all,
th
is
r
esear
ch
w
a
s
co
n
d
u
cted
to
ex
a
m
i
n
e
th
e
e
f
f
ec
t
o
f
t
y
p
e
o
f
e
x
p
r
ess
i
v
e
w
r
iti
n
g
o
n
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
a
m
o
n
g
u
n
d
er
g
r
ad
u
ates.
T
h
e
f
in
d
i
n
g
s
s
h
o
w
ed
t
h
at
o
n
l
y
p
ar
ticip
an
t
s
w
h
o
w
r
o
te
ab
o
u
t
th
eir
p
er
s
o
n
al
p
o
s
iti
v
e
ex
p
er
i
en
ce
h
a
v
e
s
i
g
n
i
f
ican
t
r
ed
u
cti
o
n
in
d
ep
r
ess
i
v
e
s
y
m
p
to
m
s
f
r
o
m
p
r
etr
ea
t
m
en
t
to
p
o
s
t
-
tr
ea
t
m
en
t,
an
d
h
a
v
e
s
i
g
n
i
f
ica
n
t
lo
w
er
d
ep
r
ess
iv
e
s
y
m
p
t
o
m
s
th
a
n
co
n
tr
o
l
w
r
i
tin
g
co
n
d
itio
n
.
T
h
is
m
a
y
b
e
d
u
e
to
th
e
p
o
s
itiv
e
af
f
ec
t
th
a
t
w
a
s
in
d
u
ce
d
d
u
r
i
n
g
t
h
e
w
r
it
in
g
s
es
s
io
n
s
b
r
o
ad
en
ed
o
n
e’
s
co
g
n
i
tiv
e
p
r
o
ce
s
s
an
d
en
ab
led
o
n
e
to
h
av
e
m
o
r
e
co
p
in
g
r
eso
u
r
ce
s
t
o
o
v
er
co
m
e
em
o
tio
n
al
ad
v
er
s
i
t
y
.
Ho
w
ev
er
,
th
e
p
o
s
iti
v
e
a
f
f
ec
t
m
i
g
h
t
n
o
t
b
e
e
x
clu
s
i
v
el
y
ex
p
l
ain
i
n
g
th
e
m
ec
h
an
is
m
o
f
b
r
o
ad
en
an
d
b
u
i
ld
m
o
d
el,
as
t
h
e
w
r
it
in
g
o
f
p
o
s
i
tiv
e
ex
p
er
ien
ce
d
id
n
o
t
el
icit
s
i
g
n
i
f
ican
tl
y
h
i
g
h
er
p
o
s
iti
v
e
a
f
f
ec
t
t
h
an
co
n
tr
o
l
w
r
i
tin
g
co
n
d
it
io
n
.
Fu
r
t
h
er
m
o
r
e,
s
u
c
h
r
ed
u
ctio
n
i
n
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
w
a
s
n
o
t
o
b
s
er
v
ed
a
m
o
n
g
p
ar
ticip
a
n
ts
w
h
o
w
r
o
te
a
b
o
u
t
th
eir
p
er
s
o
n
al
n
eg
at
iv
e
e
x
p
er
ien
ce
,
an
d
t
h
is
m
i
g
h
t
b
e
d
u
e
to
th
e
i
n
d
u
ce
d
n
eg
ati
v
e
af
f
ec
t
t
h
at
lead
to
f
ix
a
tio
n
an
d
r
u
m
i
n
atio
n
o
f
th
e
p
r
o
b
lem
.
Ho
w
ev
e
r
,
it
is
i
m
p
o
r
tan
t
to
n
o
te
th
at
t
h
es
e
ef
f
ec
t
s
o
f
n
e
g
ati
v
e
af
f
ec
t
m
ig
h
t
d
i
m
i
n
is
h
o
v
er
ti
m
e,
as
th
e
f
i
n
d
in
g
s
s
h
o
w
ed
t
h
at
t
h
e
d
ep
r
ess
iv
e
s
y
m
p
to
m
s
o
f
P
E
W
an
d
NE
W
d
id
n
o
t
d
if
f
er
s
i
g
n
if
ican
tl
y
a
t
p
o
s
t
-
tr
ea
t
m
en
t.
Fu
t
u
r
e
r
esear
c
h
ca
n
b
e
co
n
d
u
cted
to
ex
a
m
in
e
th
e
m
e
d
iatin
g
r
o
le
o
f
t
h
e
u
s
e
o
f
g
lo
b
al
o
r
lo
ca
l
f
o
cu
s
in
t
h
e
w
r
iti
n
g
s
es
s
io
n
,
as
w
e
ll
as
ex
a
m
i
n
i
n
g
th
e
lo
n
g
-
ter
m
p
s
y
ch
o
lo
g
ical
ef
f
ec
t
o
f
t
y
p
e
o
f
e
x
p
r
ess
i
v
e
w
r
iti
n
g
o
n
m
en
ta
l h
ea
lt
h
.
ACK
NO
WL
E
D
G
E
M
E
NT
S
T
h
is
s
tu
d
y
is
f
u
n
d
ed
b
y
I
n
ter
n
al
R
esear
ch
Gr
a
n
t Sc
h
e
m
e
#21
-
01
-
001
,
HE
L
P
Un
iv
er
s
i
t
y
RE
F
E
R
E
NC
E
S
[1
]
K.
A
.
Ba
ik
i
e
a
n
d
K.
W
il
h
e
l
m
,
“
E
m
o
ti
o
n
a
l
a
n
d
p
h
y
sic
a
l
h
e
a
lt
h
b
e
n
e
f
it
s
o
f
e
x
p
re
ss
iv
e
w
rit
in
g
,
”
Ad
v
a
n
c
e
s
in
Psy
c
h
ia
tric T
re
a
tme
n
t
,
v
o
l.
1
1
,
n
o
.
5
,
p
p
.
3
3
8
-
3
4
6
,
2
0
0
5
.
[2
]
J.
W
.
P
e
n
n
e
b
a
k
e
r
a
n
d
C.
K.
Ch
u
n
g
,
“
Ex
p
re
ss
iv
e
w
rit
in
g
:
Co
n
n
e
c
ti
o
n
s
to
p
h
y
sic
a
l
a
n
d
m
e
n
tal
h
e
a
lt
h
,
”
Ox
f
o
rd
Ha
n
d
b
o
o
k
o
f
He
a
lt
h
P
sy
c
h
o
lo
g
y
,
p
p
.
4
1
7
-
4
3
7
,
2
0
1
1
.
[3
]
J.
W
.
P
e
n
n
e
b
a
k
e
r
a
n
d
S
.
K.
Be
a
ll
,
“
Co
n
f
ro
n
ti
n
g
a
trau
m
a
ti
c
e
v
e
n
t:
T
o
wa
rd
a
n
u
n
d
e
rsta
n
d
i
n
g
o
f
in
h
ib
it
io
n
a
n
d
d
ise
a
se
,
”
J
o
u
rn
a
l
o
f
Ab
n
o
rm
a
l
Ps
y
c
h
o
lo
g
y
,
v
o
l.
9
5
,
n
o
.
3
,
p
.
2
7
4
,
1
9
8
6
.
[4
]
M
.
E.
F
ra
n
c
is
a
n
d
J.
W
.
P
e
n
n
e
b
a
k
e
r,
“
P
u
t
ti
n
g
stre
ss
in
t
o
w
o
rd
s:
T
h
e
im
p
a
c
t
o
f
w
rit
in
g
o
n
p
h
y
sio
lo
g
ica
l,
a
b
se
n
tee
,
a
n
d
se
lf
-
re
p
o
rted
e
m
o
ti
o
n
a
l
w
e
ll
-
b
e
in
g
m
e
a
su
re
s,”
Ame
ri
c
a
n
J
o
u
r
n
a
l
o
f
He
a
lt
h
Pr
o
m
o
ti
o
n
,
v
o
l.
6
,
n
o
.
4
,
p
p
.
2
8
0
-
2
8
7
,
1
9
9
2
,
h
tt
p
s://
d
o
i.
o
rg
/1
0
.
4
2
7
8
/0
8
9
0
-
1
1
7
1
-
6
.
4
.
2
8
0
.
[5
]
H.
E.
S
m
it
h
.
,
C.
J.
Jo
n
e
s
,
a
n
d
M
.
Ha
n
k
in
s.,
“
T
h
e
e
ff
e
c
ts
o
f
e
x
p
re
ss
iv
e
w
rit
in
g
o
n
lu
n
g
f
u
n
c
ti
o
n
,
q
u
a
li
ty
o
f
li
f
e
,
m
e
d
ica
ti
o
n
u
se
,
a
n
d
sy
m
p
to
m
s in
a
d
u
lt
s w
it
h
a
sth
m
a
:
A
ra
n
d
o
m
ize
d
c
o
n
t
ro
ll
e
d
tri
a
l,
”
Psy
c
h
o
s
o
ma
ti
c
M
e
d
icin
e
,
v
o
l.
7
7
,
n
o
.
4
,
p
p
.
4
2
9
-
4
3
7
,
2
0
1
5
.
[6
]
K.
M
.
B.
M
c
G
u
ire
,
M
.
A
.
G
re
e
n
b
e
rg
,
a
n
d
R.
G
e
v
irt
z
,
“
A
u
to
n
o
m
ic
e
ff
e
c
ts
o
f
e
x
p
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o
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[7
]
R.
J.
B
o
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h
,
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J.
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d
J.
W
.
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u
latin
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ly
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[8
]
J.
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M
.
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[9
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K.
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Exp
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.
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2
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0
1
.
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