Postural Intention Tremor Evaluation

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Sally Miller: A 27-year-old female patient presents for a follow-up appointment for generalized anxiety disorder. She has a complex history including polysubstance use disorder and borderline personality disorder but she has been doing well. She achieved remission of her symptoms over one year ago and she's been well managed on escitalopram 10 milligrams daily. She has been substance free for over one year and she's in therapy for her personality disorder. So she was managing everything. Today she's not feeling well. She reports some major psychosocial stressors and a brief substance relapse, but she stopped using all substances two days ago. The psychiatric mental health nurse practitioner notes a pronounced postural and intention tremor and suspects this is due to withdrawal from which of the following substances?

So, this is a pretty long question that comes down to a very basic concept. I mean, you get history there to put it in context, but it all comes down to you're seeing a patient who had a substance relapse, but she stopped two days ago. You note a pronounced postural and intention tremor and suspect it's due to withdrawal from what? Which one of these substances in withdrawal can produce an attention tremor?

A. Kratom

B. Opioids

C. Marijuana

D. Alcohol

And like I said, when push comes to shove, it's a very straightforward question. Which withdraw from which one of these four things will cause an intention tremor? And D is the correct answer.

When a patient stops using alcohol, they abruptly stop suppressing the sympathetic nervous system. And so, symptoms of sympathetic nervous system rebound will occur. So, I mean, you know, think about it. When you take when you drink a lot of alcohol or for that matter, benzodiazepine, it's the same phenomenon. They're both suppressing the sympathetic nervous system. So, if you suddenly stop the substance, you suddenly stop suppressing the sympathetic system and it bounces back with a vengeance. And so, the patient basically goes into sympathetic a sympathetic crisis tremor, tachycardia, hypertension, even delirium, hence the old-fashioned name delirium tremens acute mental status changes. I mean some people have strokes and seizures and it's just very unhealthy when you suddenly wake up that sympathetic nervous system and so um one of the less dramatic symptoms that you may appreciate is a postural or intention tremor.

A is not correct. Kratom is, I mean it's more of an opioid like more opioid like in its effect binding opioid receptors and so if somebody stops using that abruptly if they used a lot of it for any length of time uh the withdraw syndrome is actually simmered similar to opioid withdrawal you know the like the GI reactivation the parasympathetic rebound kind of thing and so things like um nausea vomiting diarrhea chills muscle aches, insomnia, they're more characteristic rather than the tremor.

B is not correct because like everything I just said about Kratom is what happens when you go into opioid withdrawal. Opioid withdrawal is not characterized by sympathetic system rebound. When you use opioids or Kratom you suppress the parasympathetic system and so in withdrawal you get parasympathetic rebound.

And C is not correct. I mean, marijuana doesn't have an overt physical withdrawal presentation in the way of some of these others. Although, there are people that will report after protracted use. If they suddenly stop using it, they may report aggression, anxiety-like phenomenon, and trouble sleeping, but it doesn't rise to the level of the withdrawal that you see with like alcohol, which can actually be very dangerous. With marijuana, it tends to be mild and self-limiting. And so this is really a very simple assessments in withdrawal assessments in withdrawal phenomenon.

And so the answer here is D. And it is a different type of tremor. There's a couple of different types of tremors out there if you're like really into tremor. Tremor like the name implies is it tends to get exaggerated when you're doing something. This is very different than say the resting tremor of Parkinson's disease that actually improves when the patient engages in purposeful movement with a with a parkinsonian tremor. With a resting tremor, it's most pronounced when the patient's just um doing nothing with their hands like that pill rolling tremor and then when they go to purposely do some activity, it seems to get better. And then there I mean listen, there's a whole world of tremors if you were really inclined. There's also a condition called essential tremor. We used to call it benign essential tremor. Basically, it's a tremor that's not attached to uh another serious problem. And so, even though the tremor itself can be troublesome to people, it's not associated with things like, you know, Parkinson's disease or um a substance use withdrawal. And that kind of tremor, the essential tremor, it actually tends to have a different speed if you actually counted it, which I don't know who does. I certainly never did. But that kind of trimmer is referred to as a postural tremor. And so there's all kinds of them out there. So the thing you want to remember here is that if the patient is withdrawing from uh alcohol or opioids, if they're withdrawing from an agent that suppresses the sympathetic nervous system, a tremor is anticipated on rebuild.

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