Don't Be Embarrassed by Essential Tremors

From the WebMD Archives

June 6, 2001 -- What do patriot Samuel Adams, playwright Eugene O'Neill, and actress Katharine Hepburn have in common?

They all suffered from essential tremor, or shaking of the hands, head, voice, and body, especially when active or anxious. Despite this handicap, which tends to worsen with aging, they all continued to accomplish great things as they grew older.

"Essential tremor is a very common condition," Franklin Schneier, MD, associate director of the Anxiety Disorders Clinic of New York State Psychiatric Institute in New York, tells WebMD. It affects three to four million Americans, or up to one in five of those over age 65. Because it is inherited, about half of children born to a parent with essential tremor eventually develop it, usually starting in their 30s.

"One of the most common misconceptions about essential tremor is that it is a 'benign' condition," Joseph Jankovic, MD, tells WebMD. "While in most cases essential tremor does not interfere with social or occupational functioning, this familial disorder is often quite disabling."

"Besides the physical disability that interferes with writing, feeding, dressing, and other activities of daily living, essential tremor often is a cause of embarrassment, [which] is difficult to quantitate," says Jankovic, a professor of neurology and director of the Parkinson's Disease Center and Movement Disorders Clinic at Baylor College of Medicine in Houston.

Unlike the tremor of Parkinson's disease, the shaking in essential tremor gets worse with anxiety and with simple activities like writing, eating, drinking a cup of coffee or dialing a phone. Shaking in public makes the person embarrassed, which in turn aggravates the tremor, creating a vicious circle.

"As a result, people affected with essential tremor often avoid eating out, attending parties, and participating in other social functions," Jankovic says.

Social phobia, or fear of public situations, affects up to one-third of patients with essential tremor, according to Schneier's study reported in the May issue of Journal of Clinical Psychiatry. This study compared 94 patients with essential tremor, followed in a movement disorder clinic, with 85 people without essential tremor, who were living in the community.

"This study highlights the importance of physical illness as a cause for social phobia," R. Bruce Lydiard, PhD, MD, a professor of psychiatry at the Medical University of South Carolina in Charleston, tells WebMD after reviewing the findings.

Unlike patients with social phobia unrelated to essential tremor who develop their fear in their teens, those with tremor developed fear of social situations much later, around age 50 -- when they already had problems with shaking getting worse over many years.

In these patients, activities that brought on the tremor, like writing, eating, and drinking in public, were most likely to trigger anxiety. These activities rarely provoke anxiety in patients with social phobia unrelated to essential tremor.

While Schneier's group recommends further research to determine whether treating social phobia in these patients is effective, there are simple strategies that can help people with essential tremor cope with potentially embarrassing situations.

"People with essential tremor should remember that stimulants like caffeine or nicotine may temporarily worsen tremor," Schneier says. "Fortunately there are ways to treat the tremor directly and to help minimize the embarrassment."

"Alcohol is a great drug to decrease tremor," William C. Koller, MD, a professor of clinical neurology at the University of Miami School of Medicine, tells WebMD. Koller was not involved in the study. "We tell some patients to have a drink before social engagements -- the effect lasts for about an hour."

But drink in moderation. Too much alcohol makes coordination worse and may trigger alcoholism or medical problems related to its use.

Another strategy both Koller and Lydiard recommend for some is a small dose of a drug called Inderal or other beta-blockers, used only before social outings.

"Beta-blockers tend to reduce the tremor and also can help control the increased heart rate, which accompanies exposure to the feared situation," Lydiard says. "They can relieve performance anxiety in musicians and other performers, as well as in individuals with public speaking fears."

Other treatments for tremor are also available. Doctors of severely affected patients might consider injections of Botox, surgery, or deep brain stimulation.

If you are planning to go out for a social engagement, you might want to postpone taking certain prescription drugs that can aggravate tremor, like thyroid or asthma medications. Be sure you check with your doctor first.

Here are a few other simple tips you can try on your next outing:

  • Place a napkin between cup and saucer to avoid rattling
  • Avoid awkward or uncomfortable positions
  • Use auto dial on a cell phone or have the operator place the call
  • Avoid soup, spaghetti, and other difficult foods
  • Learn deep breathing and other relaxation techniques
  • Explain your condition simply and honestly to people you meet

"From a practical perspective, treating symptoms of social anxiety, regardless of the cause, is worth a try," Lydiard says.