>Benzodiazepines are anti-anxiety drugs that calm fear but don’t prevent panic attacks, while tricyclic antidepressants like imipramine prevent panic attacks but don’t do anything about fear.3
As far as I’m aware, the claim that benzos don’t prevent panic attacks is incorrect!
We don’t like to prescribe them for that purpose, or for most cases of Generalized Anxiety Disorder, as they’re strongly habit forming and sedative, but they are very effective in that regard.
https://acnp.org/g4/GN401000130/CH.html
“The most extensively studied benzodiazepine for the treatment of panic has been the high potency triazolobenzodiazepine alprazolam. The Cross National Collaborative Panic Study (CNCPS) (44), a multicentre study conducted in two phases, is generally regarded as the most ambitious attempt to demonstrate the antipanic efficacy of alprazolam. Phase One of the CNCPS (45) randomly assigned 481 panic disorder patients (80% of whom had agoraphobia) to alprazolam or placebo, utilizing a double blind design and flexible dose schedule. All groups received their respective treatments for 8 weeks. Treatment was then discontinued over 4 weeks, and subjects were followed for 2 weeks after discontinuance. The mean dose of alprazolam employed was 5.7mg/day. Alprazolam was shown to have a rapid onset of effect, with most improvement occurring in the first week of treatment. Alprazolam was far superior to placebo on measures of panic attacks, anticipatory anxiety and phobic avoidance; at the 8 week endpoint, 55% of alprazolam treated patients were panic free, compared to 32% of those given placebo. Phase two of the Cross National Collaborative Panic Study (46) attempted to not only replicate phase one’s results in a larger sample, but also to compare alprazolam’s efficacy to that of a typical antidepressant treatment for panic. 1168 panic patients were randomly assigned to alprazolam, imipramine, or placebo for 8 weeks. This follow up study confirmed the earlier findings demonstrating superior antipanic activity of alprazolam (mean= 5.7mg/day) and imipramine (mean=155mg/day) compared with placebo, with 70% of both imipramine and alprazolam groups experiencing amelioration of panic compared to 50% for placebo. Significant drug effects were demonstrated for anticipatory anxiety and phobia. As in the phase 1 study, most of alprazolam’s beneficial effects were witnessed in the first and second weeks; imipramine, however, took four weeks or more to exert antipanic action. The main criticism of the Cross-National Study, forwarded by Marks et al (47), was that the high level (approximately 30%) of placebo dropouts due to inefficient treatment may have confounded the analysis of the endpoint data. In addition to the CNCPS, several trials have conclusively established alprazolam’s efficacy in the acute and long term treatment of panic (48-52,21). Almost all studies found alprazolam to be superior to placebo in treating phobic avoidance, reducing anticipatory anxiety, and lessening overall disability. Further, comparator studies of alprazolam and imipramine found the two medications comparable in efficacy for panic attacks, phobias, Hamilton anxiety, CGI and disability. These studies have additionally revealed alprazolam to be uniformly better tolerated than imipramine, with a quicker onset of therapeutic effect. ”
″ Clonazepam was found to be superior to placebo in 2 placebo-controlled studies.35,36 In a 9-week study,35 74% of patients treated with 1 mg/day of clonazepam (administered b.i.d. after up-titration during 3 days) and 56% of placebo-treated patients were completely free of panic attacks at the study endpoint.”
I’m not sure if it’s you or the author making the claim that they don’t prevent panic attacks, but I hope this is a small sample of the evidence base that shows them being strongly effective in that regard, which only increases our chagrin when prescribing them can lead to significant harm in the long run.
Moderately interesting news in AI image gen:
It’s been a good while since we’ve had AI chat assistants able to generate images on user request. Unfortunately, for about as long, we’ve had people being peeved at the disconnect between what they asked for, and what they actually got. Particularly annoying was the tendency for the assistants to often claim to have generated what you desired, or that they edited an image to change it, without *actually* doing that.
This was an unfortunate consequence of the LLM, being the assistant persona you speak to, and the *actual* image generator that spits out images from prompts, actually being two entirely separate entities. The LLM doesn’t have any more control over the image model than you do when running something like Midjourney or Stable Diffusion. It’s sending a prompt through a function call, getting an image in response, and then trying to modify prompts to meet user needs. Depending on how lazy the devs are, it might not even be ‘looking’ at the final output at all.
The image models, on the other hand, are a fundamentally different architecture, usually being diffusion-based (Google a better explanation, but the gist of it is that they hallucinate iteratively from a sample of random noise till it resembles the desired image) whereas LLMs use the Transformer architecture. The image models do have some understanding of semantics, but they’re far stupider than LLMs when it comes to understanding finer meaning in prompts.
This has now changed.
Almost half a year back, OpenAI [teased](https://x.com/gdb/status/1790869434174746805) the ability of their then unreleased GPT-4o to generate images *natively*. It was the LLM (more of a misnomer now than ever) actually making the image, in the same manner it could output text or audio.
The LLM doesn’t just “talk” to the image generator—it *is* the image generator, processing everything as tokens, much like it handles text or audio.
Unfortunately, we had nothing but radio silence since then, barring a few leaks of front-end code suggesting OAI would finally switch from DALLE-3 for image generation to using GPT-4o, as well as Altman’s assurances that they hadn’t canned the project on the grounds of safety.
Unfortunately for him, [Google has beaten them to the punch](https://developers.googleblog.com/en/experiment-with-gemini-20-flash-native-image-generation/) . Gemini 2.0 Flash Experimental (don’t ask) has now been blessed with the ability to directly generate images. I’m not sure if this has rolled out to the consumer Gemini app, but it’s readily accessible on their developer preview.
First impressions: [It’s good.](https://x.com/robertriachi/status/1899854394751070573)
You can generate an image, and then ask it to edit a feature. It will then edit the *original* image and present the version modified to your taste, unlike all other competitors, who would basically just re-prompt and hope for better luck on the second roll.
Image generation just got way better, at least in the realm of semantic understanding. Most of the usual give-aways of AI generated imagery, such as butchered text, are largely solved. It isn’t perfect, but you’re looking at a failure rate of 5-10% as opposed to >80% when using DALLE or Flux. It doesn’t beat Midjourney on aesthetics, but we’ll get there.
You can imagine the scope for chicanery, especially if you’re looking to generate images with large amounts of verbiage or numbers involved. I’d expect the usual censoring in consumer applications, especially since the LLM has finer control over things. But it certainly massively expands the mundane utility of image generation, and is something I’ve been looking forward to ever since I saw the capabilities demoed.
Flash 2.0 Experimental is also a model that’s dirt cheap on the API, and while image gen definitely burns more tokens, it’s a trivial expense. I’d strongly expect Google to make this free just to steal OAI’s thunder.