Essential Tremor and Anxiety

Anxiety is pretty common; something everyone experiences from time to time. But for some people, anxiety is more than just an occasional jitter or nervous butterflies in the stomach. Anxiety can be a very real, very debilitating condition if left untreated.

As with essential tremor (ET), the exact cause of anxiety isn’t fully understood. Life experiences appear to trigger anxiety disorders in people who are already prone to becoming anxious, although inherited traits may also be a factor. People affected by a chronic medical condition, like ET, often worry about issues related to their condition. They worry about the effectiveness of their treatment options and what the future will hold for them and their families. They worry about how their shaking hands, head or voice are perceived when they are out in public; if there will be judgmental stares from perfect strangers or whispers of detox and addiction. Because ET is poorly understood and is unknown to most of the general public, those who have it often feel like they are singled-out because of their shaking. They feel there is a constant spotlight highlighting their trembling body. All these feelings can create a cycle of anxiety.

When does anxiety change from normal anxiousness to a medical condition? Everyone experiences the symptoms of anxiety differently and to different degrees. Some people may feel only slightly nervous in certain situations, while others may have constant feelings of powerlessness, impending danger, panic or doom. Their heart rate may increase very quickly, and they may even hyperventilate. Some people may feel tired or weak, and lose interest in doing things that may cause them anxiety. They may have trouble concentrating, able only to focus on the present worry.

When feelings of worry continue for long periods of time and begin to interfere with work, personal relationships or other important parts of life, it may be time to see a doctor. There are many types of anxiety, just like there are many types of tremor. A medical professional is needed to get an accurate diagnosis and to discuss appropriate treatment options.

Here are some common anxiety types seen in conjunction with essential tremor:

Social anxiety disorder (social phobia) involves high levels of anxiety, fear, and avoidance of social situations due to feelings of embarrassment, self-consciousness, and concern about being judged or viewed negatively by others.

Panic disorder involves repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks). People may have feelings of impending doom, shortness of breath, heart palpitations or chest pain. These feelings may occur at any time, not necessarily during an anxiety-provoking situation. It is important to discuss these symptoms with your doctor, as they can be very similar to signs of a heart attack.

Agoraphobia is anxiety about, and often avoidance of, places or situations where you might feel trapped or helpless if you start to feel panicky or experience embarrassing symptoms, such as losing control.

Generalized anxiety disorder includes persistent and excessive anxiety and worry about activities or events — even ordinary, routine issues. The worry is usually out of proportion to the actual circumstance, is difficult to control, and interferes with the person’s ability to focus. It often occurs along with other anxiety disorders or depression.

Anxiety is very common and can be diagnosed by most physicians. People who experience anxiety should not blame themselves, psychosocial stress, or their ET. People with chronic anxiety are known to have abnormally active brain pathways that may be the cause of their anxiousness. So, telling someone with anxiety to “stop worrying so much” is the same as telling someone with ET to “hold still”. It is not something that can be easily controlled. Like ET, having anxiety is nothing to be ashamed of. Thankfully, anxiety is often very treatable.

The two main treatments for anxiety disorders are psychotherapy and medication. Also known as talk therapy or psychological counseling, psychotherapy involves working with a trained therapist to reduce anxiety symptoms. Cognitive behavioral therapy is one of the most effective forms of psychotherapy for anxiety disorders. Generally a short-term treatment, cognitive behavioral therapy focuses on teaching specific skills to gradually return to those activities once avoided because of anxiety.

In addition, general good health habitats can help reduce symptoms of both ET and anxiety:

Exercise is a powerful stress reducer. It may improve your mood and help you stay healthy.

Avoid alcohol and other sedatives. These substances can worsen anxiety.

Quit smoking and drinking coffee. Both nicotine and caffeine can worsen anxiety and exacerbate ET.

Use relaxation techniques. Visualization techniques, meditation and yoga are examples of relaxation techniques that can ease anxiety.

Get plenty of rest. Do what you can to make sure you’re getting enough sleep to feel rested. If you aren’t sleeping well, see your doctor.

Eat healthy. Focus on vegetables, fruits, whole grains and fish.

Several types of medications can be used in conjunction with psychotherapy to treat anxiety disorders. Low-dose antidepressant medications are a common treatment option and are often very effective. There are even a few options that may help reduce tremor as well. Benzodiazepines like clonazepam (Klonopin®), diazepam (Valium®), lorazepam (Ativan®), and alprazolam (Xanax®) may be useful in the treatment of both anxiety and ET. Care should be taken with these medications as they need to be taken exactly as directed and may become habit forming. Talk with your doctor about benefits, risks and possible side effects.

Although anxiety and depression are often seen together, they are very different conditions. The table to the left shows the differences between the two conditions.

Anxiety disorders can cause tremor; however, this is a different tremor type than ET. Tremor due to anxiety presents as a fine, rapid shaking of the hands and may also be referred to as enhanced physiologic tremor. This tremor does not cause a persistent, disabling tremor and is often related to a particular situation . If tremor is seen in other parts of the body or if the tremor is disabling and persistent, there is most likely an underlying cause, either from a neurological disorder or tremor-causing medication.

Approximately 40 million Americans, ages 18 and older, or about 18.1 percent of people have an anxiety disorder. There have been studies which evaluated the prevalence of anxiety disorders among those affected with ET. One study showed 32.7 percent of patients with ET also suffered from anxiety, a more than 14 percent increase over the general population. In addition, international studies have clearly indicated those individuals suffering from ET accompanied by a secondary anxiety disorder definitely show a higher level of disability than just having ET or anxiety disorder alone.

Depression is also found among those with ET and can be found in conjunction with anxiety. Just over six percent of the general population suffers from depression, while in one study, 21.7 percent of patients with ET also suffered the effects of depression.

It can become a vicious cycle. A person has a tremor, and then becomes depressed about the tremor. They develop anxiety about their tremor, which causes an increase in the tremor, which causes an increase in feelings of depression about the tremor and which causes an increase in feelings of anxiety about the tremor, which causes an increase in tremor … without treatment, the cycle could spiral out of control.

If you feel like you are suffering from chronic anxiety, something more than the occasional anxious moments, speak to your doctor. There is help. You are not alone. 

Contributions for this article came from several members of the IETF Medical Advisory Board:

Prof. Arif Herekar, MD – Baqai Medical University in Karachi, Pakistan
Rodger Elble, MD, PhD – Southern IL University School of Medicine in Springfield, IL
Kelly Lyons, PhD – University of Kansas Medical Center in Kansas City, KS and President of the IETF Board of Directors.