Nervousness and Shaking:
Are they the Same Thing?


Gary E Cordingley, MD, PhD
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.


(C) 2005 by Gary Cordingley