Symptoms & causation

Understanding the symptoms of Essential Tremor

Essential Tremor (ET) does not look the same in everyone. Shaking in the hands is often the first sign, but tremor can also affect the head, voice or legs and some people have undetectable internal tremor that isn’t visible to others.

The impact on daily life varies and some people struggle with tasks like writing or eating, while others feel worn out from trying to manage the tremor in silence.

Symptoms can be physical (motor), such as visible or internal tremor, or non-physical (non-motor), such as changes in mood, energy or confidence.

ET can begin at any age. Early on, it may not be recognised as a problem and some people live with tremor for years without realising it is a medical condition. Over time, symptoms can worsen and the tremor may spread to other parts of the body.

Motor symptoms

The hallmark of ET is shaking in the hands and usually happens during movement, so is called an “action” or “movement” tremor. This contrasts with Parkinson’s tremor, which happens when the person is at rest. People with ET will typically get a tremor when they try to write, eat or hold a glass. It often affects both sides of their body, although not always equally and its severity can vary from day to day.

Stress, tiredness, caffeine, stimulant/other medications and extreme temperatures can make symptoms worse.

ET can also affect the:

head – causing nodding up and down or shaking side to side (about 30% of people with ET).
voice – producing a shaky or quivering sound (around 20% of people).
legs or trunk – less common, but present in some cases.
internal part of the body – creating a hidden shaking sensation, often described as a quiver or vibration that others cannot see.

Other motor-related issues

ET can cause subtle changes to balance and walking. People with ET might feel less confident when walking in a straight line, especially if asked to place one foot directly in front of the other (tandem gait). Some people experience fatigue that doesn’t improve with rest and this is more common when tremor affects the head. While ET does not usually cause obvious cerebellar problems (like those seen in other movement disorders), mild signs such as midline ataxia, which is slight unsteadiness in the trunk, can occur.

Non-motor symptoms

Researchers and clinicians increasingly recognise ET as a complex neurological disorder that affects far more than movement. Some non-motor symptoms might develop or be associated with a diagnosis of ET.

Cognitive changes

People with this condition may also notice small but frustrating changes in their thinking. They might forget names or words, take longer to find the correct phrase, or lose their train of thought mid-conversation. Some people find it harder to plan, organise tasks or solve problems. For a proportion of people (15–29%), these changes can be part of a mild cognitive impairment and in a smaller number of older-onset cases (5–11%) dementia can develop. Head or midline tremor more often links with trouble concentrating and remembering things.

Mood and emotional symptoms

Living with ET often harms emotional wellbeing. Many people experience anxiety or depression, which occur about twice as frequently as in the general population. Tremor can cause embarrassment, especially when eating, drinking or writing in public, leading some people to avoid social activities altogether. People frequently report low self-esteem, apathy and isolation and the condition can create a sense of helplessness or loss of dignity. Because few people understand ET, others may mistakenly assume someone with ET is nervous, frail or intoxicated, adding to the emotional burden.

Sleep problems

Many people with ET say their sleep is not as restful as it once was. They can wake up frequently during the night, have trouble falling asleep or wake up feeling unrefreshed. Some people also experience excessive daytime sleepiness, which can make it harder to focus or enjoy activities. Sleep problems can be more noticeable when tremor affects the head or midline.

Sensory changes

Hearing changes are more common in ET than in people of the same age without the condition. They might find they need to turn the television volume up more than before, or that it’s harder to follow conversations in noisy places. Sometimes their sense of smell may also be affected.

The bigger picture

The presence of these non-motor symptoms supports the view that ET is a neurodegenerative condition rather than a purely monosymptomatic tremor disorder. Together, motor and non-motor symptoms can significantly affect daily activities, work and quality of life. Some people may need to adjust their jobs, avoid social situations or retire early because of the impact of ET.

What causes Essential Tremor?

The exact cause of ET is not known. Researchers believe it’s likely a combination of changes in the brain and genetic factors.

What’s happening in the brain?

ET does not have a single known cause. Research shows that overactive signals in areas of the brain responsible for movement may play a role. When these brain connections don’t work smoothly, tremor can result. Scientists have seen small changes in brain cells in some people with ET, but not everyone shows these changes.

Is Essential Tremor genetic?

Yes, it often is. Around half of people with ET have a family history of the condition. If a parent has ET, each of their children has about a 50% chance of inheriting it. This pattern is called “autosomal dominant”.

That said, scientists haven’t found a single “ET gene”. It’s more likely that several genes are involved and different families may carry different ones. Researchers have studied a gene called LINGO1, but they require further research to understand its role in ET.

Could the environment play a role?

Research on environmental causes is still in development. Some studies have investigated whether exposure to substances such as heavy metals, pesticides, or certain toxins may trigger or make ET worse. However, researchers have not found definitive proof that these substances cause ET.

It is essential to understand that stress, diet or personality does not cause ET. While stress may make tremors more noticeable, it does not cause the condition. ET is a neurological disorder with genetic and brain-related causes, not something that develops from lifestyle factors or personal characteristics.

It’s not just “nerves”

For many years, people called ET the “shakes” and thought it was just a sign of being nervous. But that’s a myth. ET is a neurological condition, meaning it starts in the brain, not the emotions.

In summary

We don’t know the exact cause of ET yet. Inherited genes and subtle changes in brain activity seem to link to it. Research is ongoing and what we learn in the future may help improve treatments. The good news is: even though we can’t cure ET, there are effective ways to manage the symptoms and help people with the condition to live well.