by How to Tell If a Tremor Is Neurological or Psychological: A Comprehensive Guide
How to Tell If a Tremor Is Neurological or Psychological: A Comprehensive Guide
1. Why the Type of Tremor Matters
Feeling a tremor can be frightening, and many people immediately worry about serious brain disease or Parkinson’s. A tremor, however, is a symptom, not a diagnosis by itself, and its cause can be neurological, psychological (also called functional), or even medication-related or metabolic. Distinguishing neurological from psychological tremor matters because the treatment pathways, prognosis, and specialists involved are very different.
2. What Exactly Is a Tremor?
A tremor is an involuntary, rhythmic, back‑and‑forth movement caused by alternating contractions of opposing muscle groups. It can affect the hands, arms, head, face, voice, trunk, or legs, and may appear at rest, when holding a posture, or during movement.
Clinicians first confirm that the movement is truly a tremor (and not, for example, a tic, myoclonus, or dystonia), then look at when it appears (rest vs action), which body parts are involved, and whether any other neurological signs are present.
3. What Is a Neurological Tremor?
A neurological tremor is caused by structural or functional problems in the nervous system, such as the cerebellum, basal ganglia, or their connections.
Common neurological tremor syndromes include:
-
Essential tremor – usually a bilateral hand tremor that worsens with action or posture (e.g., holding a cup), often with family history and slow progression over years.
-
Parkinsonian tremor – typically a “rest tremor” that appears when the limb is relaxed (e.g., hand resting in the lap), often accompanied by bradykinesia, rigidity, and reduced arm swing.
Neurological tremors are often relatively consistent in pattern and gradually progressive, and usually sit within a recognisable movement-disorder syndrome.
4. What Is a Psychological (Functional / Psychogenic) Tremor?
Psychological, functional, or psychogenic tremor is a tremor where the movement pattern does not match typical organic (structural) neurological diseases, and is instead linked to how the brain controls movement under emotional or psychological stress.
Key points about psychogenic tremor:
-
Often begins abruptly, sometimes after a stressful life event, illness, injury, or surgery.
-
Can be intermittent, with spontaneous remissions and recurrences, and may “move” from one body region to another.
-
Brain imaging and standard neurological tests are usually normal, which supports, but does not alone prove, a functional origin.
5. Onset and Time Course: Slow vs Sudden
How the tremor begins and evolves over time is one of the strongest clues.
Neurological tremors commonly:
-
Start insidiously, with a mild shake that slowly worsens over months or years.
-
Spread gradually to additional body parts as the underlying condition progresses (e.g., essential tremor involving hands, then head, then voice).
Psychogenic tremors commonly:
-
Have abrupt onset, often described as “it just started one day at full intensity.”
-
Show waxing and waning history, with periods of complete or near-complete remission, then sudden flares.
-
May change distribution over time, for example, starting in one arm, then appearing in the leg or head without a typical organic pattern.
This does not mean that every sudden tremor is psychological; medication side effects, toxins, or stroke can also cause acute tremor. History and examination must be integrated.
6. What Doctors Look For on Examination
A skilled examination is central to distinguishing neurological from psychological tremors. Clinicians assess tremor at rest, with posture, and during action, and then add specific “tricks” to test consistency, distractibility, and entrainment.
Typical neurological tremor features:
-
Consistency: The frequency and direction are relatively stable from moment to moment.
-
Context‑dependent pattern:
-
Rest tremor fits Parkinsonian patterns.
-
Postural/action tremor fits essential or cerebellar tremor patterns.
-
-
Accompanying signs: rigidity, bradykinesia, gait changes, ataxia, abnormal eye movements, or other focal neurological signs.
Typical psychogenic tremor features:
-
Distractibility: Tremor amplitude or frequency decreases or disappears when the patient is engaged in a mental task (e.g., serial 7s) or simultaneous motor task (e.g., tapping with the other hand).
-
Variability: Rapid changes in amplitude, frequency, or direction (for example, irregular, non‑rhythmic shifts that are not typical of organic tremor).
-
Entrainment: When the unaffected limb is asked to tap rhythmically at a certain frequency, the tremoring limb’s rhythm may shift to match (entrain) that tapping, which is characteristic of psychogenic tremor.
-
“Give‑way” or inconsistent weakness, bizarre postures, or other non‑physiological patterns that do not fit known neurological anatomy.
None of these signs alone is absolute, but a cluster of psychogenic features strongly supports a functional diagnosis.
7. The Role of Medical and Psychological History
History does not just cover the tremor; it also explores background health, life events, and mental health.
Favouring neurological tremor:
-
Longstanding high blood pressure, diabetes, stroke, multiple sclerosis, or degenerative conditions.
-
Family history of essential tremor or Parkinson’s disease, especially if relatives have similar shaking.
Favouring psychogenic tremor:
-
Recent major stressors (bereavement, relationship breakdown, job loss), physical trauma, surgery, or a frightening health event.
-
Past or current anxiety, depression, PTSD, or other psychiatric conditions.
-
History of multiple unexplained neurological symptoms, frequent ER visits with normal tests, or a pattern of functional neurological disorder.
Importantly, having mental health difficulties does not “prove” that a tremor is psychological, nor does having a neurological disease rule out a functional overlay. Mixed presentations do occur.
8. Tests and Investigations: What They Can and Cannot Show
Most of the differentiation is clinical, but tests help rule out organic causes and sometimes add positive clues.
Common investigations:
-
Blood tests – to check thyroid function, electrolytes, liver and kidney function, and drug levels, since metabolic problems can worsen tremor.
-
Brain imaging (MRI/CT) – usually normal in pure psychogenic tremor, but may show stroke, demyelination, or structural lesions in neurological tremors.
-
Electromyography (EMG) and accelerometry – can measure tremor frequency and muscle activation patterns. Psychogenic tremor may show co‑activation of agonist and antagonist muscles at onset and variable frequency, features that have been found to separate psychogenic from organic tremor in some studies.
For essential tremor, diagnosis is often based on clinical pattern and family history, not a single “positive test.” For psychogenic tremor, there is no blood test or scan that alone makes the diagnosis; it rests on positive clinical signs such as distractibility and entrainment in the right context.
9. How Treatment Differs: Matching Care to Cause
Because the mechanisms are different, the management approach also differs significantly.
For neurological tremors:
-
Medications
-
Essential tremor: beta‑blockers (like propranolol) or anticonvulsants (like primidone) are commonly used.
-
Parkinsonian tremor: dopaminergic medications used for Parkinson’s disease can reduce tremor in many cases.
-
-
Procedures
-
In severe, medication‑refractory essential or Parkinsonian tremor, deep brain stimulation (DBS) or focused ultrasound thalamotomy may be considered.
-
-
Rehabilitation
-
Physiotherapy and occupational therapy help with coordination, strength, and practical adaptations (weighted utensils, modified writing tools).
-
For psychological (functional) tremors:
-
Clear explanation and validation: A respectful explanation that the tremor is real, but due to functional brain control rather than structural damage, can itself reduce symptoms in some people.
-
Psychological therapies: Cognitive‑behavioural therapy (CBT), trauma‑focused therapy, or other evidence‑based psychotherapies can address underlying stress, anxiety, or maladaptive movement patterns.
-
Multidisciplinary rehabilitation: Functional neurological disorder clinics often combine neurology, psychology, physiotherapy, and occupational therapy to retrain movement and reduce symptom focus.
-
Medication: Antidepressants or anxiolytics may be used when there is significant depression or anxiety, but they are not “anti‑tremor” drugs in the same sense as those for essential tremor or Parkinson’s.
A key practical point: giving high‑dose neurological tremor drugs to a person whose tremor is functional is unlikely to help and can cause side effects. Correct early classification prevents this.
10. Practical Red Flags and When to Seek Help
Anyone with a new, persistent, or disabling tremor should see a clinician, ideally a neurologist or movement‑disorder specialist, for a proper assessment. Certain features deserve urgent attention:
-
Tremor associated with sudden weakness, speech changes, facial droop, or severe headache (possible stroke or other acute neurological event).
-
Tremor plus rapidly progressive gait disturbance, falls, or cognitive decline.
-
Tremor beginning after starting a new medication, drug, or exposure to toxins.
For chronic or fluctuating tremors with prominent stress links, early involvement of both neurology and mental health professionals is beneficial, as functional movement disorders have better outcomes when recognised and treated early.
You May Know
Is Tremor Curable or Lifelong?
