long has been known that tremor may be a prominent
Tremor in Acute (Problemata
It symptom
and Chronic Anxiety
Peter J. Tyrer, MRCP, Malcolm H. Lader, MD
Finger tremor between 2 and 32 hertz in frequency was measured
in two groups of anxious subjects. In one study 32 normal subjects
were made acutely anxious by experimental stressors, and their
tremor was measured and compared with rest conditions. In a sec-
ond study, tremor was measured in 28 chronically anxious psychiat-
ric patients and in 28 control subjects matched for age and sex. No
differences were found in the peak frequency of tremor in any of the
groups, but the amount of tremor was greater in the anxious sub-
jects. The differences were greatest at tremor in the frequency range
between 6 and 17 Hz. The results support the view that the differ-
ences between normal and anxious tremors are those of degree, not
of nature.
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in anxiety. This was noted by Aristotle
947" 10) and in the book of Ecclesiastes (12:1,
3), and the common expressions, "shivering with fear,"
"quaking with horror," and "chattering teeth," all illus¬
trate the association between tremor and emotion. Like
much that is common knowledge, however, the actual ori¬
gins of the phenomenon are unknown, although the in¬
crease of tremor that occurs in states of excitement is bet¬
ter understood. The earliest objective measurements of
tremor were carried out in the 19th century by the tam¬
bour method, in which the movements of the trembling
limb were transmitted by a rubber diaphragm to a pen
that traced out the movements on a smoked drum.'·2 Con¬
sidering the relative crudity of this method, the results ob¬
tained were remarkably good. Charcot2 was able to divide
pathological tremor into three groups based on frequency
alone: slow (four to five tremors per second), found in dis¬
seminated sclerosis, senility, and Parkinson disease; inter¬
mediate (5Vè to 6 per second), which he classified as "hys¬
terical"; and rapid or vibratile (eight to nine per second),
characteristic of thyrotoxicosis, mercury poisoning, alco¬
holism, and general paralysis of the insane.
Although Charcot's classification proved to be correct
for parkinsonian tremor, this was not so for the other
categories. Several years earlier1 it had been shown that
tremor of about 10 hertz consistently accompanied volun¬
tary muscular activity, and most studies of physiological
tremor have found this frequency peak to be surprisingly
constant under a wide range of experimental conditions.
Tremor measured in anxious and neurotic patients has
produced a wider range of results: Graham4 found a mean
frequency of 14 Hz; Redfearn,5 in a study of neurotic pa¬
tients, described a peak of 8 Hz for tremor measured in a
subgroup of anxiety states; and Carrie" found a peak of 7
to 10 Hz, with a greater amplitude in men than in women.
The amount of tremor recorded in anxious subjects was
invariably greater than in normal subjects in all these
studies.
At least some of the differences in these studies may be
explained by different techniques of measurement. In re¬
cent years improvement in these techniques had led to
more reliable results. Advantage was taken of these to
Accepted for publication March 8, 1974.
From the Department of Psychiatry, Institute of Psychiatry, University
of London.
Reprint requests to the Departmant of Psychiatry, South Block, South-
ampton General Hospital, Southampton, England (Dr. Tyrer).

Fig 1.—Apparatus for recording
record tremor in a range of conditions in which anxiety
was deliberately induced in normal subjects, in psychiatric
outpatients with chronic anxiety, and in a matched control
group.
Methods
The technique used in the studies involved the measurement of
acceleration with a commercially available subminiature acceler-
ometer (Ether BLA 2 model, Pye Industries Ltd.). This comprises
two active inductive bridge arms, each wound within a magnetic
shield. The air gap between the bridge arms is controlled by a
seismically suspended magnetic armature. The accelerometer is
supplied with only two bridge arms and it is necessary to make up
the two remaining arms and incorporate a dry battery (1.5 v) to
complete the Wheatstone bridge. The accelerometer is light (2.5
gm) and compact (17x7x5 mm), and is easily attached to the
trembling part without altering the inertia of the system. The ac¬
celerometer measures movement in the vertical plane only, so ar¬
tifacts due to lateral movement are not recorded. The range of the
accelerometer is much greater than that normally required for
physiological purposes (± 20 g), but it is sensitive to an accuracy
of ± 5% and has a frequency response of 1 to 100 Hz. The accel¬
erometer has been used successfully in several studies of postural
tremor and gives reliable recordings.'
Before recording, the accelerometer was taped to the middle
finger of the left hand immediately behind the fingernail. The left
forearm was supported to the level of the wrist joint and the wrist
fixed with a Velcro band. The subject was asked to look straight
ahead during the period of recording, and the left hand was held
horizontally with the forearm pronated and the fingers slightly
abducted. Preliminary tests showed that this gave reliable record¬
ings.
The analog signals representing acceleration of the trembling
finger were amplified 10s to 104 times by an amplifier (Grass
P511C) with the half amplitude upper and lower frequencies set at
1,000 Hz and 0.3 Hz, respectively. The amplification factor was
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Analog to digital
<*- Eight samples of 4.8 sec
*- Autocorrelation function
«- Power spectral density
Computer
tremor.
chosen after visual inspection of the acceleration on an os¬
cilloscope (Tektronix 502A). Recordings lasted for about a minute
on each occasion. During recording, the analog signals represent¬
ing acceleration were filtered to allow only frequencies between 2
and 32 Hz to pass (Kemo Filters Ltd.) before on-line analysis,
using a computer (PDP 12A, Digital Equipment Corporation). In
the analysis, eight epochs of tremor, each comprising 4.8 seconds,
were displayed individually on the computer oscilloscope. The
tremor was also recorded simultaneously on one channel of mag¬
netic tape, using an analog tape recorder (Ampex SP 300). The to¬
tal sample was subjected to power spectral analysis, a technique
derived from communications engineering,8 in which the amount
of tremor in each hertz between 2 and 32 Hz was calculated by au¬
tocorrelation, followed by a Fourier transform. To normalize the
distribution of data, logarithmic conversion was carried out be¬
fore statistical testing. The full procedure is shown diagrammat-
ically in Figure 1.
Anxiety was induced in 32 paid, normal subjects by three
stressful situations: (1) electric shocks given to the upper arm at a
level that the subject was just able to tolerate, (2) the same proce¬
dure following the taking of isoproterenol sulfate (Medihaler-Iso),
and (3) exposure to a phobic stimulus (usually of animals such as
snakes, spiders, or rats) that was chosen in advance to produce an
increase in anxiety that was unpleasant but not sufficiently dis¬
turbing to disrupt the experiment. The situations were repeated
in the same order for each subject. Both before and after exposure
to these stresses subjects were tested at rest, so that for each sub¬
ject there were five tremor recordings. Three types of stress were
chosen because of the difficulties of creating anxiety in an experi¬
mental situation that is similar to real-life anxiety. The phobic sit¬
uation approximated most closely normally experienced anxiety,
but lacked the standardization of the other two stresses. Isopro¬
terenol was included as well as electric shocks, because cate-
cholamines are known to increase anxiety in anxiety-provoking
situations.8
The 28 psychiatric patients all had a primary diagnosis of anxi¬
ety state, and symptoms of anxiety were present continuously for
 at least the previous four months. All were drug-free at the time
of assessment, and none had taken phenothiazines or anti-
depressants in the three weeks prior to testing. The 28 controls
were matched individually with the patients for age (± 3 years)
and sex. Both patients and control subjects were unfamiliar with
the experimental situation before testing.
Results
The scores for the 32 acutely anxious subjects were
tested by a split-plot analysis of variance, variation
within subjects being estimated against residual variance,
with between-subject variance removed. The scores for
the chronically anxious patients and control subjects were
exposed to a simple one-way analysis of variance.
Tremor profiles for the groups are illustrated (Fig 2 and
3).
Although the psychiatric patients had the most severe
tremor, the pattern shown for acute and chronic anxiety is
essentially the same. There is an increase in tremor over
the physiological range (6 to 14 Hz), but little difference at
other frequencies. Analysis of the peak frequency, mea-
5l
4-
1-
0J
10 12 14
Frequency,
Fig 2.—Tremor in acute anxiety. For simplicity, results for
Fig 3.—Tremor
6i
1-
0-1
Frequency, Hz
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sured to the nearest 0.5 Hz for each subject, yielded F ra¬
tios of 0.42 in the acute anxiety study and 0.15 in the
chronic anxiety study, thus showing that, despite the
changes in amount of tremor, the main frequency re¬
mained essentially constant. The differences in amount of
tremor were analyzed in 4-Hz frequency bands between 2
and 29 Hz, and the results are shown in the Table.
Comment
The results support the view that there is little qual¬
itative difference between anxious and normal tremors.
The changes in tremor that occur in anxiety are consistent
with increased secretion of catecholamines, particularly
adrenaline. It is now well established that there is a rise in
the level of circulating catecholamines during anxiety,1012
and that catecholamines increase the amplitude of physi¬
ological tremor.11 As isoproterenol is itself a cate-
cholamine, it is notable that when this was given together
with electric shocks the pattern of tremor was very sim¬
ilar to that in other stress situations (Table). There are
other factors, possibly cortical in origin and certainly in-
Shocks alone
At rest
16 18 20
Hz
only one stress and rest situation are shown.
in chronic anxiety.
Patients
Control subjects
16
 Frequency Band Analysis of Tremor*
Acute Anxiety
Chronic Anxiety
Tremor Shock and
Frequency, Shock Isopro- Control
Hz Rest Alone terenol Phobia Rest F Ratio Subjects Patients F Ratio
2- 5 4.60 4.19 4.39 4.36 4.01' 0.13 4.24 7.69 3.53
6- 9 11.77 12.39 13.32 12.35 11.25 2.55t 11.60 17.75 11.28t
10-13 9.86 10.56 10.80 10.33 9.65 0.97 9.29 15.02 15.73§
14-17 2.40 1.81 1.90 1.70 1.67 0.42 0.99 5.88 14.49§
18-21 1.16 0.64 1.30 0.67 0.65 0.97 0.33 2.51 3.35
22-25 0.90 0.53 1.19 0.77 0.93 0.83 0.71 2.73 2.71
26-29 0.67 0.58 0.79 0.42 0.90 0.61 0.24 2.12 2.85
* The figures given are in log, units,
t <.05.
* P<.01.
§ P<.001.

dependent of catecholamines, that may affect tremor am¬ The classification of tremors is still not a satisfactory
plitude,11 and these may be responsible for some of the dif¬ one and we have advanced little since Charcot's time. It is
ferences between the two studies. For example, the now clear that classification based on frequency is of lim¬

relatively greater proportion of faster tremor in the 10- to
17-Hz range in chronic anxiety is not shown in acute anxi¬
ety (Table). This corroborates, to some extent, previous
suggestions of increased tremor at faster frequencies in
anxious patients.11"'
At frequencies above 17 Hz, anxiety has little effect on
tremor. The subsidiary peak at 24 to 27 Hz has been noted
before,"117 and may be due to local factors such as intrinsic
finger tremor. It certainly does not appear to have any
clinical importance.
ited value. As far as anxiety is concerned it would seem
preferable to confine descriptions of tremor to terms of
quantity instead of suggesting that there are qualitative
differences that distinguish it from other types of tremor.
Terms that imply that there is such a difference, such as
"coarse" and "fine," are misleading; they imply differ¬
ences in frequency that do not exist.
This work was carried out while Dr. Tyrer had a Medical Research Coun¬
cil Clinical Research Fellowship.

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