Can anxiety cause tremors?

Can Anxiety Cause Tremor?

Yes, anxiety can directly cause tremor, which manifests as an enhanced physiological tremor primarily affecting the upper limbs during postural and kinetic activities. 1

Clinical Recognition of Anxiety-Related Tremor

Physical Manifestations

• Tremor is a recognized sign of anxiety on mental status examination, appearing alongside other autonomic symptoms including fidgetiness, restlessness, hypervigilance, and "nervous" habits 1
• The American Society of Clinical Oncology identifies trembling as a core physical symptom of anxiety, occurring with panic attacks, sweating, tachypnea, tachycardia, palpitations, and sweaty palms 1

Tremor Characteristics in Anxiety Disorders

• Research demonstrates that tremor in generalized anxiety disorder is an enhanced physiological tremor affecting postural and kinetic movements, involving only the upper limbs without other body parts 2
• The kinetic component of anxiety-related tremor can be functionally disabling and warrants specific treatment 2

Distinguishing Anxiety-Related Tremor from Other Causes

Key Differential Considerations

• Medical and substance-induced causes of anxiety (and associated tremor) must be diagnosed and treated first 1
• Tremor can occur as a withdrawal symptom from medications like benzodiazepines or opioids, which may be misinterpreted as anxiety 1, 3
• Medication-induced tremor from SSRIs (8% incidence with sertraline) or antipsychotics must be excluded, as these are common anxiety treatments that paradoxically cause tremor 1, 4

Assessment Approach

• When moderate to severe anxiety symptoms are detected, conduct a diagnostic assessment to identify the nature and extent of anxiety symptoms and determine if an anxiety disorder is present 1
• Evaluate for autonomic hyperreactivity as a biological vulnerability for anxiety disorders 1
• Symptoms of anxiety can be enhanced by or misinterpreted as withdrawal symptoms when patients are anxious about medication changes 1

Treatment Implications

Pharmacological Management

• Both propranolol and benzodiazepines (alprazolam) have demonstrated similar favorable effects on anxiety-related tremor 2
• For situational anxiety with tremor (e.g., performance anxiety), propranolol 20-40 mg taken 1 hour before the event is recommended after screening for contraindications including asthma, COPD, bradycardia, heart block, or heart failure 5
• Propranolol works by blocking peripheral effects of adrenaline, reducing rapid heart rate, tremors, and nervousness during anxiety-provoking situations 5

When to Treat Tremor Specifically

• If tremor causes functional disability only during periods of stress and anxiety, propranolol or benzodiazepines can be used during those specific periods 6
• For chronic anxiety with persistent tremor, SSRIs/SNRIs are first-line for the underlying anxiety disorder, though these may paradoxically cause tremor as a side effect (8% incidence) 1, 5, 4

Clinical Pitfalls to Avoid

Common Diagnostic Errors

• Do not overlook that anxiety symptoms themselves may be secondary to other medical conditions requiring identification and treatment 1
• Tremor listed as an anxiety sign is nonspecific and may be absent; these physical signs are largely adjunctive to other diagnostic information 1
• Serotonin syndrome can present with tremors, clonus, and hyperreflexia when combining serotonergic medications, and must be distinguished from anxiety-related tremor 1

Medication Considerations

• SSRIs commonly prescribed for anxiety can cause tremor (8% incidence), behavioral activation, and agitation, particularly early in treatment or with dose increases 1, 4
• Antipsychotic medications can cause tremor through extrapyramidal effects, and neuroleptic malignant syndrome presents with tremor, rigidity, and autonomic instability 1
• Abrupt benzodiazepine discontinuation causes tremor as a withdrawal symptom, which can be confused with anxiety recurrence 3

Referral Indications

• Severe anxiety or agitation, risk of harm to self/others, or presence of psychosis requires referral to a psychiatrist or equivalently trained professional 1
• Consider specialized evaluation if tremor persists despite anxiety treatment or if characteristics suggest essential tremor rather than anxiety-enhanced physiological tremor 2, 6