Louis et al.

Journal of Clinical Movement Disorders (2016) 3:11
DOI 10.1186/s40734-016-0039-6

RESEARCH ARTICLE Open Access

Depressive symptoms can amplify
embarrassment in essential tremor
Elan D. Louis1,2,3*, Stephanie Cosentino4,5 and Edward D. Huey4,5,6,7

Abstract
Background: Embarrassment can be a considerable problem for patients with essential tremor (ET) and is a major
motivator for treatment. Depression is also a common feature of ET; as many as 35 % of patients report moderate
to severe depressive symptoms. Our goal was to assess the associations between these motor and psychosocial
factors (tremor, depression, embarrassment) in ET, with a particular interest in more fully assessing the possible
association between depression and embarrassment.
Methods: Ninety one ET cases (age 70.4 ± 12.8 years) enrolled in a prospective, clinical-epidemiological study.
Depressive symptoms were assessed with the Center for Epidemiological Studies Depression Scale (CESD-10, 0–30
[maximum]), embarrassment, with the Essential Tremor Embarrassment Assessment (ETEA, 0–70 [maximum]), and
action tremor, with a detailed in-person neurological examination.
Results: Higher CESD-10 score was significantly associated with higher ETEA score (p = 0.005), but not with
increasing tremor severity (p = 0.94). In stratified analyses, cases with no or minimal depressive symptoms had the
lowest ETEA scores, cases with moderate depressive symptoms had intermediate ETEA scores, and cases with
severe depressive symptoms had the highest ETEA scores (p = 0.01). Furthermore, at each level of tremor severity,
cases with more depressive symptoms had more embarrassment.
Conclusions: Depressive symptoms seem to be more than a secondary response to the tremor in ET; they seem to
amplify the level of embarrassment and, in addition to their own importance, seem to be a driver of other
important clinical outcomes. Earlier treatment of depressive symptoms in ET patients could lessen the burden of
secondary embarrassment.
Keywords: Essential tremor, Non-motor, Depression, Embarrassment, Clinical, Treatment

Background signaling, and avoidance of others [3]. Embarrassment
According to some estimates, 60 % of essential tremor about tremor is a considerable problem for patients with
(ET) patients report embarrassment surrounding their ET [1, 4–7]. It is one of the two main motivators for ET
tremor [1]. Embarrassment, classified as a “self-conscious” patients to initiate medical therapy [1, 4–6] and it is a par-
emotion along with shame and guilt, and in contrast to ticularly strong predictor of receptivity to deep brain
“basic” emotions such as anger and joy [2], often arises stimulation (DBS) surgery among patients with ET [8].
when someone violates a social rule or expectation [3]. Moreover, feelings of embarrassment can lead to avoid-
Embarrassment is associated with autonomic reactivity in- ance of social situations and social isolation [9]. Indeed,
cluding increased heart rate, blood pressure, and sweating handling embarrassment and the social effects of tremor
and behavioral reactions including gaze avoidance, regret has been highlighted by ET patients as one of the top
issues not being addressed in their care [10].
Depressive symptoms and depression have been associ-
* Correspondence: elan.louis@yale.edu
1
Division of Movement Disorders, Department of Neurology, Yale School of ated with ET in numerous case–control studies [11–17];
Medicine, Yale University, LCI 710, 15 York Street, PO Box 208018, New according to some estimates, as many as 35 % of patients
Haven, CT 06520-8018, USA report moderate to severe depressive symptoms [17].
2
Department of Chronic Disease Epidemiology, Yale School of Public Health,
Yale University, New Haven, CT, USA Similar to embarrassment, depression in ET is often
Full list of author information is available at the end of the article

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≥13). tremor medication. The mean 3 for each item) different depressive symptoms. Chi-square New York. and there is emerging evidence that embarrassment and its effects on the patient’s desire for depression may be a primary feature of the disease.4 ± 12. medications. with able and valid instrument [22]. group. a formal assessment of embar.D.6 %) having no or minimal depressive symptoms. To incorporate both sets of thors (E. received a diagnosis of ET from their treating neurologist Several CESD-10 cut-offs have been recommended for and were confined to a geographical area within 2 h driv. CUMC. of whom one (1. Center for Epidemiological Studies Depression Scale (CESD-10) (0–30 [higher scores indicate greater depres. The aim was to use the videotape to care- The goal of these analyses was to assess the associations fully validate ET diagnoses using rigorous research-grade between these motor and psychosocial factors (ie.70. and depression may all examination. in the absence of Parkinson’s disease. Thus. by a senior neurologist specializing in movement disorders with a particular interest in more fully assessing the pos. tremor.7 %) having severe depressive symptoms. The large majority of cases were derived from two sources: (1) a computerized billing Statistical analyses database of ET patients at the Neurological Institute of Data were analyzed in SPSS (Version 22.) who confirmed the ET diagnoses using Washing- sible association between depression and embarrassment. 20]. as in a prior set of analyses [25].7 years.5 ± 6. Scores > 20 have high sensitivity and specifi- enrollment. which included tests of postural and kinetic occur in ET. divided cases into three groups based on their CESD-10 ent with other movement disorders were excluded. depression. score: 0–9 (no or minimal depressive symptoms). the Essential 47 (51. 4–7. depression has not been well instrument [4]. dystonia As described previously. CESD-10 scores were also stratified worker administered a series of structured clinical ques.0). This suggests that de. nov Test p values = 0. into quartiles (≤3. the trained research atical cut-points. Analysis of data was also approved by the city for the diagnosis of Major Depressive Disorder as Internal Review Board at Yale School of Medicine. (40. Six (6. the associations tremors and assessments for the presence of other involun- among them have not been the subject of previous analyses. To derive strictly mathem- During the in-person evaluation. speaking in front of a pression itself could drive other clinical outcomes in ET.6 %) [maximal embarrassment]) [15] was administered to ET cases had CESD-10 scores > 20. One. The CESD is a self-report measure The 91 ET cases had a mean age of 70.) reviewed the office records of identified recommendations. Ninety-one cases were enrolled after parametric tests (eg. 10–19 The CUMC Internal Review Board approved of all study (moderate depressive symptoms). 37 Tremor Embarrassment Assessment (ETEA). Written informed consent was obtained upon symptoms). Overall.D. which is a valid and reliable [11. 0. conservative score ≥20 [24]. and depression) in individuals with ET. In addition. Results sive symptoms]) [21]. clinical features. 0. tionnaires (demographics. such as embarrassment.35. defined in the DSM [26–28].L. ton Heights-Inwood Genetic Study of ET (WHIGET) diag- nostic criteria (moderate or greater amplitude kinetic Methods tremor [tremor rating ≥2] during three or more tests or a Participants and evaluation head tremor. those with diagnoses of or physical signs consist. 14]. ≥20 (severe depressive procedures. Prior to enrollment. Journal of Clinical Movement Disorders (2016) 3:11 Page 2 of 6 viewed as a secondary response to the disabling condition patients [4]. social situations). hence. an assess. Pearson’s r) were used when asses- the embarrassment assessment was added. Total tremor score. Each item is rated from 0 to 5. Center (CUMC) [19. and (2) advertisements to members of tests were used to assess associations within categorical the International Essential Tremor Foundation. All cases underwent a standardized videotaped tremor Although tremor. each videotape was reviewed embarrassment. score were all normally distributed (Kolmogorov-Smir- During that time period. (E. one of the au.1 %) was . of situations (eg.Louis et al.L. eating in public. The ETEA. embarrassment. rassment was added. Linear regression models were used to assess the asso- family history). Cases had all sing these variables. and likely impact one another. The research worker also administered the ciations between variables. ETEA score and CESD-10 hundred-forty-one cases were enrolled (2009–2014). CESD-10 score was 9.8 years and a of 10 questions about the frequency of experiencing (0 to mean tremor duration of 36. 8–12. data. diagnostic criteria [23]. as well as embarrassment in a variety preceding motor symptoms [18]. rather than representing a passive with higher scores indicating greater embarrassment [4]. ET cases were enrolled in a or another cause) [23]. however. and a more ing distance of CUMC. It is a reli. comprises 14 questions that assess overall studied in ET [11]. The neurologist also rated postural clinical-epidemiological study of the epidemiology of and kinetic tremor (range = 0–3) during 12 videotaped tests movement disorders at Columbia University Medical and computed a total tremor score (range = 0–36). respectively). response to the motor symptoms.9 ± 18. including a score ≥10 [21]. we patients. tary movements.7 %) having moderate depressive symptoms and 7 ment of tremor-related embarrassment (range = 0–70 (7.2 (range = 0–26) (Table 1).67.

despite the fact that they had similar levels Non-Hispanic white race 86 (94.6).1 ± 2.4 ± 12. making this an important constellation ≥ 13 (highest quartile) 17.3 (n = 7) depressive symptoms had the highest ETEA scores (n = 5. As noted above. cases with no or minimal depressive symp. including somatic symptoms such as poor appetite. level of embarrassment was 50 % higher ETEA score (Pearson’s r = 0.6 ± 5.8 ± 18.Louis et al. Cases with severe ETEA score (Pearson’s r = 0. fewest depressive symptoms) had the lowest creased energy. Table 3).9. p = 0. Indeed. higher CESD-10 score was associated CESD-10 score 9. and score was 24. there ment.6. This was associated ET 28 (30.01).4 ± 1. 7 of 7 (100 %) cases with se- ET or tremor 58 (63. Table 2).037. cases with severe depressive symptoms had the highest Higher total tremor score was associated with higher embarrassment scores (p = 0.4 ± 1.8 sive symptoms.94). psychomotor retardation. cases 0–9 (no or minimal depressive symptom category) 4. cases and cases with severe depressive symptoms had the who had more depressive symptoms had more embarrass- highest ETEA scores (p = 0.9 ± 17. cases with no or minimal depressive symptoms CESD-10 score had the lowest ETEA scores (n = 28.2) In a subgroup analysis of 58 patients with family history Voice tremor on examination 24 (26.2 many ET patients. 21. 19. cases with moderate depressive also taking an antidepressant medication. most depressive symptoms) had the highest Age in years 70. Journal of Clinical Movement Disorders (2016) 3:11 Page 3 of 6 Table 1 Demographic and clinical characteristics of 91 ET cases quartile (ie.6 ± 16. it is surprising ETEA score 24.04). Table 2).7 ± 2. and cases with severe ≥ 20 (severe depressive symptom category) 23. thus. mean level of embar- rassment was 50 % higher in cases with severe depressive Age of onset of tremor in years 37.9 vs.9 ± 18. CESD-10 score 36.0 vs. that is.5 ± 6. despite the fact that they had similar levels of tremor Higher CESD-10 score was associated with higher severity. the converse is the case. depression.4 vs.1 ± 4. In the current study. de- 10 quartile (ie.7) vere depressive symptoms had taken medication for tremor Total tremor score 20.7 toms (31.02).7 (n = 47) with moderate depressive symptoms had intermediate 10–19 (moderate depressive symptom category) 13. p = 0.2 Discussion 4–7 (second quartile) 5. at each level of tremor severity.2 ± 16.30. 1). minimal depressive symptoms despite nearly identical toms had the lowest ETEA scores. p = 0. p = 0. While it is conceivable that greater embarrassment was a significant association between CESD-10 score could lead to more depression. Fur- (range = 0–26) thermore.4) of ET or tremor.005). Indeed. Hence.1 of motor and psychosocial factors. Fur. 1). Head (neck) tremor on examination 32 (35.2 ± 2.6) ≥20) had higher ETEA scores than those with fewer depres- Education in years 16.2) (linear regression analysis.2 ± 1.7 ± 18. The mean ETEA symptoms had intermediate embarrassment scores. 2).8 levels of embarrassment (Fig.2 with higher ETEA score (Pearson’s r = 0. 28/47 (59. Table 3) despite nearly identical total Family history of: tremor scores (19. cases in the lowest CESD.001.5) of tremor severity (Table 3). cases Tremor Embarrassment Assessment) with no or minimal depressive symptoms had the lowest embarrassment scores. levels of embarrassment and cases in the highest CESD-10 Embarrassment is unlikely to be the direct cause of any of . 19.9 (range = 0–61). Similarly. The CESD-10 score).5 (n = 37) ETEA scores (n = 25.37. (range = 33–96) Cases with severe depressive symptoms (CESD-10 score Female gender 47 (51. in cases with severe depressive symptoms than those with thermore. higher depres- Values represent mean ± standard deviation or number (percentage) sive symptom scores were associated with significantly CESD-10 (Center for Epidemiological Studies Depression Scale). higher CESD-10 score (Pearson’s r = 0.6 %) of those with no or minimal depressive symptoms (chi-square test = 4. p = 0. Fig.9 that the associations between these factors have not been (range = 0–61) delineated previously.005.2 Tremor.4). Indeed.29. that depressive symptoms At each level of tremor severity (ie.0 ± 2.2 ± 16. at each total tremor are amplifying the level of embarrassment.1 symptoms than those with no or minimal depressive symp- Tremor duration in years 36. higher level of depressive symptoms was associated scale measures the full range of depressive symptoms with more embarrassment. 28.27. Table 3).008. ≤ 3 (lowest quartile) 1. and embarrassment may co-occur in 8–12 (third quartile) 10. depressive symptoms (CESD-10 score ≥20) had higher however.016 and see Fig. p = 0. and insomnia. cases with moderate total tremor scores.8) with greater medication usage. it is more plausible that quartile and ETEA score (p = 0. depressive symptoms had intermediate ETEA scores.01. higher total tremor score was not associated with ETEA scores than those with fewer depressive symptoms. ETEA (Essential greater levels of embarrassment (p = 0.

[25]. 32]. guilt. Despite its high prevalence. preceding More broadly. thus.01a CESD-10 score quartiles ≤ 3 (lowest quartile) 15. in the current study. although in a prior pression is associated with an increase in the distress and set of analyses. its relationship to the motor features of crease. Studies that examine the response to tremor. At each level of tremor severity (ie.6 ± 16. during an episode of major de. more than half of the cases had moderate or Table 2 Association between CESD-10 and ETEA scores in 91 ET severe depressive symptoms. 2 ETEA score by CESD-10 score. most depressive symptoms) had the highest levels of embarrassment these depressive symptoms. This finding has precedent in symptoms are a driver of other important clinical out. we showed that depressive symptoms were disability associated with chronic pain [29].2 4–7 (second quartile) 20.4 ± 16. 1 ETEA score by total tremor score in each CESD-10 quartile. controls in numerous studies [11–17]. Depression often acts as an the causes. higher level of depressive symptoms was associated with more embarrassment. and embarrassment in.4 ± 17. secondary and Parkinson’s disease [31. ETEA (Essential Tremor Embarrassment Assessment) a Linear regression analysis with ETEA score as dependent variable and CESD Fig.4 ≥ 20 (severe depressive symptoms) 31.6 ± 16. Journal of Clinical Movement Disorders (2016) 3:11 Page 4 of 6 Fig. clinical correlates of depression and its relationships with sion have been reported as more prevalent in ET cases than other disease features in ET are therefore of importance.3 ± 12. Self-conscious a strong predictor of tremor-related quality of life in ET emotions including shame. fewest depressive symptoms) had the lowest levels of embarrassment and cases in the highest CESD-10 quartile (ie. often dramatically. including Huntington’s disease comes in ET rather than merely a passive. Emerging evidence suggests that pressive disorder [30].29.4 10–19 (moderate depressive symptoms) 28. depression may even be a primary feature of ET.001b Values represent mean ± standard deviation or number (percentage) CESD-10 (Center for Epidemiological Studies Depression Scale). these data also suggest that depressive the motor features [18]. Indeed.2 ± 17.7 p = 0. at each total tremor score). ET may be complex. De. other movement disorders. score category as the independent variable b ciated with higher ETEA score (Pearson’s r = 0. p = 0. Furthermore. Depressive symptoms and/or depres.005) Linear regression analysis with ETEA score as dependent variable and CESD score quartile as the independent variable .3 8–12 (third quartile) 26.6 p = 0. Higher CESD-10 score was asso.Louis et al. cases ETEA score CESD-10 score category 0–9 (no or minimal depressive symptoms) 19. have not been studied in any detail [11]. cases in the lowest CESD-10 quartile (ie.5 ≥ 13 (highest quartile) 31. effects and natural history of depression in ET amplifier of related symptoms in psychiatric disorders.9 ± 16.

(ETEA).6. indi. ETEA score and medication usage in 91 ET cases CESD-10 score category n Total tremor score ETEA score Number (%) who had been prescribed medication for tremor 0–9 (no or minimal depressive symptoms) 47 19. Center for Epidemiological Studies Depression Scale. The mean CESD-10 tremor in ET. First.2 19. Future studies could further assess lead to avoidance of social situations and social isolation such relationships. total tremor score. 4–6] and can further of embarrassment. validated screening instrument. as has been reported in ET in the past [11–17]. Washington Heights-Inwood Genetic Study of ET several of the key variables. (DBS). In summary.9 ± 9. . Earlier treatment of cating a higher burden of depressive symptoms among depressive symptoms in ET patients might be a strategy to our cases. Journal of Clinical Movement Disorders (2016) 3:11 Page 5 of 6 Table 3 CESD-10 score category. One interpretation of these data is that depres- these analyes. (CES-D). tions.Louis et al.0 31. the study cohort was enrolled prospectively. in addition to reducing anxiety. Third. so Abbreviations that we are not able to directly address issues of causality.4 24 (64. greater Our cases had a mean CESD-10 score of 9. such information could tremor has been highlighted by patients as one of the have supplemented the data we collected on current top issues not being addressed in their current care [10]. this was not a retrospective study or chart erate [33]. While the effect of depression treatment has not been The study also had several strengths. Essential tremor. 17] and it could impact upon levels for initiating medical therapy [1. the effect size for the knowledge.5 ± 6.1 ± 5. they increase the importance of treating depressive For example. Acknowledgements it is possible that more in-depth psychiatric assessments None.Deep brain stimulation. Columbia University Medical Center. Second. Conclusions referral to a psychotherapist who utilizes a symptom. Fourth. despite the fact that they be preferable to insight-oriented psychodynamic therapy. but not of symptoms. (CBT). it may reduce embarrassment as the relationship between ET and other self-conscious well. the study was cross-sectional. Essential limited our ability to detect associations. Indeed. ETEA (Essential Tremor Embarrassment Assessment) a Linear regression analysis with total tremor score as dependent variable and CESD score category as the independent variable b Linear regression analysis with ETEA score as dependent variable and CESD score category as the independent variable One clinical implication of the current findings is that could have uncovered additional associations of interest. lessen the burden of secondary embarrassment.9 ± 16.84.01b Values represent mean ± standard deviation or number (percentage) CESD-10 (Center for Epidemiological Studies Depression Scale). However. we did not collect data on past [9]. The findings of the current study also suggest review.2.4 ± 16. to our specifically studied in ET patients. with that the treatment of depression with psychotherapy in a standardized assessment. Furthermore. p <0. (PST).8 28.6 7 (100) p = 0. First. patients with ET should assess and target embarrassment as well as the more usual depressive symptoms. it is the only study to have assessed this par- treatment of depressive symptoms with antidepressant ticular gap in knowledge and these particular associa- medication in patients with Parkinson’s disease is mod. (ET). the sample size was modest and this may have Epidemiological Studies Depression Scale. anxiety is also a common feature patients [1. and embarrassment and depressive symptoms.4 ± 17.0 ± 2. In particular. the Tremor Embarrassment Assessment. (CUMC). 4–6]. Center for Second. we found that cases with severe depressive based therapy method such as Cognitive-Behavioral symptoms had higher embarrassment scores than those Therapy (CBT) or Problem-Solving Therapy (PST) could with fewer depressive symptoms.6 ± 6. It is one of the two main motivators of patients with ET [9.001).9) ≥20 (severe depressive symptoms) 7 19. comes such as embarrassment. was the enrollment of control subjects of sive symptoms are more than a secondary response to the similar age (n = 177.4 28 (59. (WHIGET). This study should be interpreted within the context of certain limitations.5 years). In ET patients with depression and prominent embarrassment. Essential Tremor Embarrassment study was able to detect significant main effects between Assessment. a value that was themselves.7 ± 4. had similar levels of tremor severity.36a p = 0. they also seem to drive other important out- lower than that of our cases (t test = 3.6) 10–19 (moderate depressive symptoms) 37 22. handling the embarrassing social effects of history of depression in our cases. depressive symptoms were assessed with a brief. the relationship between symptoms of symptoms in patients with ET as. including social anxiety. 74. in addition to being clinically important in score of these controls was only 6. A tremor severity was not associated with more depressive feature of this clinical-epidemiological study. Embarrassment is a considerable problem for ET emotions. depressive symptoms.

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