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Dr. Frank
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 8999
Experience:  Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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Last week I had a severe emotional episode; the denouement

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Last week I had a severe emotional episode; the denouement of two months chronic panic/anxiety symptoms. During the episode, I started to feel sensory symptoms spread across my face, throat, upper and lower limbs. Now the muscles in my face/lips tremor, twitch, jerk; my throat tremors when I swallow, making eating/drinking difficult, and I have burning pain all over my body. My voice has a gravel sound to it when I speak and my throat gets sore. I wake up tremoring internally in my neck, arms and legs. My fingers feel stiff and slowly jiggle from side to side when I stretch them. I don't tremor when I write, type or do most fine motor skills.

My question is: could the severe outburst have triggered a pathological tremor with such a fast progression? My symptoms have improved slightly, but not enough to make me feel reassured. My family is small, no history of tremor in any members. I'm 36, female, non smoker, generally healthy.

Thank you.
Welcome to Just Answer. I am an Adult Neurologist and was contacted to answer your question.

Hello. Have you had any evaluation for this anxiety/panic complaint? A cardiac evaluation? Seen a neurologist or a psychiatrist? Tested for metabolic conditions like thyroid disease, hypoglycemia/diabetes?

Dr Frank T
Customer: replied 3 years ago.

Tests include: basic metabolic panel, Wilson's, heavy metals, thyroid/antibodies, electrolytes, cardiac stress test, ANA levels, Lyme, etc. All normal. Non diabetic.

Had Neuro consult on Monday: DX enhanced physiologic tremor secondary to panic/anxiety. MRI of head and neck, EEG and EMG happening next week.

Head/face/throat/body symptoms came on fast and are unremitting; however, I've had a slow side to side jiggle of a few fingers for a couple of years now. Worried my emotional episode has triggered a spread of pathological tremor.
The MRI of the neck especially will exclude more peripheral nerve causes for this tremor, the EMG exam, if they do a tremor analysis will determine if this is a central tremor, or from the peripheral nerve. A EEG to exclude a paroxysmal condition like seizure, is unlikely. There are newer tests like Datscan, which can look at dopamine levels in the brain as seen in essential tremor vs. parkinsons disease. I do not know if your emotional episode was a cause or effect of your disorder. That is really the job of the neurologist. Please get back to me if you have questions Dr Frank T
Customer: replied 3 years ago.
Neuro said negative for Parkinsons, ALS, etc. Also said my symptoms don't present like ET; impossible for such fast progression of symptoms in the absence of severe family history or early age onset (under 15 years old.) Do you have an opinion on this? Do you think it's worth pursuing a second opinion consult? Do you have an opinion on the DX of enhanced physiological tremor?

Is there something specific I should mention at the EMG to ensure a tremor analysis is done, and can you please speak more about how an EMG determines if a tremor is central or peripheral in origin?

Thank you.
You should ask about doing a tremor analysis as part of the surface EMG recording. In peripheral nerve problems, you can see an alternating pattern in agonist vs. antagonist muscles along the same dermatome. In central tremors, this type of finding is absent. If you have a peripheral pattern, then you consider cervical stenosis (pinched nerve in the neck) or neuromuscular/myopathic disorders.

Enhanced physiologic tremor is a natural tremor that is enhanced by secondary disease, like thyroid, diabetes, alcohol withdrawal, etc. You need a cause to make that diagnosis, hence your previous blood evaluations. I would wait for your entire evaluation to conclude before deciding on a second opinion, as you really have not screened for all causes ok? Dr frank t
Customer: replied 3 years ago.
Last question: if all testing comes back normal, what is the most likely or logical explanation for my symptoms?
If all of your testing comes back normal, I would say very good news, because in neurology, although we can diagnose, we are not as good in treating these problems. There is functional tremor, which is a psychogenic tremor that comes on in severe emotional trauma. I do not know you, do not know your story or exam, but if everything is normal, that would be your diagnosis. Essential tremor can come on early in life rarely as well, so I would disagree in part with your neurologist. that would also stay on the list. Dr Frank T
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Customer: replied 3 years ago.
Hi Dr. Frank, some of my symptoms have gotten better, but the internal shaking when I wake up waxes and wanes. I actually dreamed Last night that I was in an earthquake and I woke up shaking internally, very violently. It calmed down after a bit but my body is left with a pins and needles sensation all over. I'm afraid to go to bed at night for fear of shaking in the morning. I'm getting an EMG on Friday, will it be able to pick up internal tremors?
Hello. The EMG will show changes in volitional activity if you are having tremor expressed in the muscles, but an "internal" tremor will not be seen. Dr Frank T
Customer: replied 3 years ago.
Do you mean an internal tremor will not be "seen" by the EMG itself, or visually by the doctor doing the test? Does an EMG pick up enhanced physiologic tremor and essential tremor? Someone told me to ask for a tremorgraph; I have not heard of this before. Do you know what this is and can I ask for this service? Is it the same thing as an accelerometer?

HI. The EMG picks up muscle activity, using surface or needle recording, you can see muscle activity is specific muscles and look at the interaction between different muscles by using different channels on the machine, so you can look at frequency, the burst of activity causing the tremor contraction, and the synchrony between other muscles. Accelerometers can measure movement of the limb across a joint in one plane, but are crude in comparison to EMG. By looking at the frequency of the contraction, you can make statements as to if this is enhanced physiologic, essential or neuropathic. But an "internal" tremor, without movement,is not going to be noted on an EMG. I personally have not heard of a tremorgraph, and could not find anything in the neuro literature. I hope that answers your question Dr Frank T
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