training. The theoretical literature also acknowledges the overlap among these approaches (as well as incomplete understanding of the mechanisms at work when these interventions are used) (APA, 2004; Harvey et al., 2003). Further explanation of the various psychotherapies can be found in Appendix A.

SUMMARY OF THE MAJOR CLINICAL PRACTICE GUIDELINES

To be sure that the committee was aware of all pharmacotherapies and psychotherapies in general clinical use, a search was conducted for clinical practice guidelines developed by major professional organizations. The committee reviewed clinical practice guidelines developed by the Management of Post-traumatic Stress Working Group of VA and the Department of Defense (DoD), the American Psychiatric Association (APA), the British National Institute for Clinical Excellence (NICE), the International Society for Traumatic Stress Studies (ISTSS), and the Australian Centre for Posttraumatic Mental Health of the Australian National Health and Medical Research Council. The committee made no judgments about the quality of these guidelines in the processes used or conclusions reached, but found them useful in defining the domain of clinical PTSD interventions.

The VA/DoD Clinical Practice Guideline (2004) classifies four psychotherapy treatments as being of significant benefit: cognitive therapy, exposure therapy, stress inoculation therapy, and EMDR. Treatment modalities considered to offer some benefit include imagery rehearsal therapy, psychodynamic therapy, and PTSD patient education. The guidelines also identified two adjunctive treatments: dialectical behavioral therapy and hypnosis. Among the pharmacotherapy interventions, only one group, the SSRIs, was classified as being of significant benefit. Medications identified as having some benefit include TCAs, MAOIs, sympatholytics, and novel antidepressants. Anticonvulsants, atypical antipsychotics, nonbenzodiazepine hypnotics, and the antianxiety drug buspirone were identified as having unknown benefit. Finally, drugs with no benefit or possible harm include benzodiazepines and typical antipsychotics.

The APA (2004) practice guidelines grouped its recommendations into categories: (I) recommended with substantial clinical confidence; (II) recommended with moderate clinical confidence; and (III) may be recommended on the basis of individual circumstances. SSRIs were the only pharmacotherapy rated as category I, while TCAs and MAOIs were rated category II, and benzodiazepines, anticonvulsants, antipsychotics and adrenergic inhibitors were rated category III. The guidelines found clinical effects in studies with women with chronic PTSD related to rape or assault are particularly noteworthy in the SSRI class. The evidence for MAOIs was limited to male combat veterans. For benzodiazepines, the evidence identified by



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