Nervousness and Shaking: Are They the Same Thing?

Are you nervous? If so, does that mean you're anxious, or that your hands shake? The distinction can be crucial.

Asked if they feel nervous, some people respond by holding up their unshaking hands, watching them a few seconds and saying, "I don't think so. They look steady to me!" This unexpected answer illustrates the confusion many people have about anxiety, tremors, and what they have to do with each other.

A psychiatrist friend proposed a useful labeling system. He refers to internal states of anxiety, worry and upset as "inner nerves." By contrast, when outward, visible tremulousness is present, he calls that "outer nerves." The distinction is important because the causes and treatments of "inner nerves" and "outer nerves" are almost entirely different from each other.

It's not hard to see where the confusion arises. Most people with tremulousness experience worsening of their shaking in states of high emotion, like anger, fear—-or even joy. They notice improvement in tremor when they are feeling unstressed, and their companions see their tremoring disappear completely when they sleep. Yet, it's not the emotional states that caused the tremor. Instead, the emotions just increased or decreased a tremor that was already there for another reason.

Although tremor can occur in almost any part of the body, shaking of the hands is most common and can be caused by a variety of conditions. Tremors can also vary in their appearance, and the appearance of the tremor can narrow down the list of possibilities.

Here are the three basic tremor patterns:

#1. Tremors most evident while the hands are at rest. A typical situation is that the hands shake worse while in the person's lap than while in the air or when put to use. This pattern is seen most often with Parkinson's disease or with medications that can produce a Parkinson-like condition, including most antipsychotic and anti-nausea drugs.

#2. Tremors most evident with the hands held in the air. (A related pattern involves tremor maximal when the hands are put to use, for example, to write a letter or hold a cup of water.) This pattern can be seen on an inherited basis, with an overactive thyroid gland, with certain medications (including drugs for asthma, seizures or manic-depressive illness) and for no good reason at all (called essential tremor).

#3. Tremors that worsen when the moving hand approaches a target, for example, to pick up a pencil or scratch one's nose. This relatively uncommon pattern is seen with damage to the part of the brain known as the cerebellum, located in the back of the head.

To the extent that the underlying problem can be fixed, the tremor will usually improve as well. So if someone's tremor is due to an overactive thyroid, the tremor will improve when the thyroid problem is corrected. If a tremor is due to Parkinson's disease, then it will get better with medication for this condition. And if medication itself is causing the problem, then a dose-reduction or substitution of another drug might do the trick.

What if an underlying cause is not found, or correction of an underlying problem doesn't make the tremor go away? Treatment might still be available. In the case of tremors most evident with the hands in the air, certain medications might provide meaningful improvement, including primidone (brand name Mysoline), propranolol (Inderal), metoprolol (Lopressor) and gabapentin (Neurontin).

People with anxiety (inner nerves) respond best to anxiety-relieving medications and counseling. But medications that relieve anxiety do not help tremors (outer nerves) much, except to the extent that they make the patient drowsy. This is because all tremors improve with drowsiness. However, being perpetually drowsy is not a favorable trade-off for controlling tremor.

Who should get treated? It's an individual decision. Assuming that underlying problems have already been screened for, symptomatic treatment of inner nerves or outer nerves depends on the answers to two questions:

#1. Does the symptom cause distress?
#2. Does the symptom interfere with usual activities?

An affirmative answer to either question means that treatment should be considered.

About the Author

Gary Cordingley, MD, PhD, is a clinical neurologist, teacher and researcher. For more health-related articles, see his website at:
http://www.cordingleyneurology.com