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Lithium-induced disabling tremor
THEODORE VAN PUTTEN, M.D.
Lithium-induced disabling tremor ABSTRACT: Six patients with manic-depressive illness developed
disabling postural tremors at low blood lithium levels. Each patient had either a pre-existing essential (heredofamilial) tremor or a family history of essential tremor. Lithium thus appears to exacerbate essential tremor. Fine hand tremor, a frequent, persistent side effect of lithium therapy,' does not yield to antiparkinson drugs. Generally the tremor causes the patient only slight inconvenience. This report, however, concerns six patients out of 46 patients studied who developed disabling postural tremors with lithium therapy. Each of these six patients had either a pre-existing benign essential (heredofamilial) tremor or a family history of essential tremor. Forty-six patients with manic-depressive illness were given lithium carbonate. Maintenance blood lithium levels were conventional, ranging between 0.6 and l.l mEq/liter. All the patients were examined for essential tremor before therapy. Criteria for the diagnosis of benign essential tremor were: postural hand PSYCHOSOMATICS
tremor since early adulthood, family history of postural tremor, no evidence of other neurological disease (specifically Parkinson's disease or hyperthyroidism).2 Case reports Forty patients with no preexisting essential tremor or family history of tremor did not develop a significant postural tremor with lithium therapy. At lithium levels ranging between 0.5 and 0.8 mEq/liter six patients developed disabling postural tremors. Here is a description of their cases. Case t A 65-year-old banker with severe bipolar manic-depressive illness had had a moderate essential hand tremor, a barely noticeable head tremor, and associated tremulousness of the voice (presumably due to respiratory muscle and larynx involvement 2) since adolescence. He was
self-conscious about the tremor and he customarily postponed signing bank documents until he felt particularly well, when he would always press hard with the pen to mask the tremor. At a blood lithium level of0.6 mEq/liter, the tremor became so severe that he could no longer write or drink from a cup, and his voice became very quavery. This marked exacerbation of the tremor was not significantly ameliorated by 80 mg of propranolol daily,) 40 mg of diazepam daily, or 1200 mg of meprobamate daily,4 and the lithium had to be discontinued. Casel A 45-year-old physician with bipolar manic-depressive illness had had a mild hand tremor and occasional tremulousness of the voice since late adolescence. At maintenance blood lithium levels of 0.6 mEq/liter, his voice became more quavery and his hand tremor exacerbated to the point of interfering with suturing. Blood lithium levels of 0.7 to 0.8 mEq/liter resulted in mild dysarthria, presumably because of exacerbation of an associated tremor of the tongue. s Meprobamate, 1200 mg daily, had some ameliorative effect. Case 3
A 65-year-old man with unipolar mania had had a moderate hand 27
Disabling tremor
tremor since adolescence. Maintenance blood lithium levels of 0.7 mEq/liter produced a conspicuous head tremor, and the hand tremor became so severe that he could no longer feed himself. Propranolol, diazepam, and meprobamate were of no value, and lithium had to be discontinued. Case 4 A 45-year-old surgeon with bipolar
manic-depressive illness developed an intention tremor with maintenance blood lithium levels of 0.7 mEq/liter. The tremor was intensified by tension and became a morbid preoccupation, as it would "act up unpredictably" in surgery. Before lithium therapy he had had no noticeable tremor; however, the family history was positive for essential tremor. Cases 5 and 6 In two men with bipolar depressive illness and mild essential tremor, lithium initially exacerbated the tremor to the point of incapacitation. However, as the lithium attenuated psychotic agitation, the tremor became less disabling; and maintenance treatment with lithium, albeit with a moderate tremor, was preferable to abject psychosis.
If conventional blood lithium levels produce a disabling tremor, our experiences suggest that the patient either had a preexisting benign essential tremor or a family history of essential tremor. Essential tremor is exacerbated even by low blood lithium levels and can be a relative contraindication to treatment with lithium. Essential heredofamilial tremor, a common disorder characterized by tremor of a postural nature, may involve any part of the body but is usually more prominent in the hands and arms.4.5 If the tremor involves the muscles of the larynx, respiration, and tongue, low blood lithium levels may also exacerbate (or produce) voice quavering or dysarthria or both. 2•S Patients often make no mention of their constitutional peculiarity and not infrequently they equate the tremor with "nervousness."s The tremor is transmitted as
Dr. Van Pullen is a staff psychiatrist at the Veterans Administration Hospital, Brentwood, Calif, and associate professor of psychiatry in residence at the University of California. Los Angeles. Reprint requests to Dr. Van PUllen at Brentwood VA Hospital, Los Angeles, CA 90073.
PSYCHOSOMATICS
an autosomal dominant with variable penetrance, and there is no known association between familial tremor and affective illness. 6 Relief with alcohol is rather characteristic. According to some investigators, propranolol has a beneficial effect on essential tremor. 7•S Trials of propranolol dosage of up to 80 mg daily were not useful in three of the patients described, but the dosage may have been too low in these cases.7•S 0
REFERENCES I. Schou M: Lithium in psychiatric therapy and prophylaxis. J Psychiat Res 6:67-95, 1968. 2. Benign essential tremor, editorial. Lancet 2:471-472, 1972. 3. Kirk L, Baastrum PC, Schou M: Propranolol and lithium-induced tremor. Lancet 1:839, 1972: 4. Critchley E: Clinical manifestations of essential tremor. J Neurol Neurosurg Psychiat 35:365-372, 1972. 5. Critchley M: Observations on essential (heredofamilial) tremor. Brain 72:113139,1949. 6. Larsson T, Sjogren T: Essential tremor: A clinical and genetic population study. Acta Psychiat Neurologica Scand, suppl 144:1-173, 1960. 7. Tolosa ES, Loewenson RB: Essential tremor: Treatment with propranolol. Neurology 25:1041-1044,1975. 8. Sweet RD, Blumberg J, Lee JE, et al: Propranolol treatment of essential tremor. Neurology 24:64-67, 1974.
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Lithium-induced disabling tremor ABSTRACT: Six patients with manic-depressive illness developed
disabling postural tremors at low blood lithium levels. Each patient had either a pre-existing essential (heredofamilial) tremor or a family history of essential tremor. Lithium thus appears to exacerbate essential tremor. Fine hand tremor, a frequent, persistent side effect of lithium therapy,' does not yield to antiparkinson drugs. Generally the tremor causes the patient only slight inconvenience. This report, however, concerns six patients out of 46 patients studied who developed disabling postural tremors with lithium therapy. Each of these six patients had either a pre-existing benign essential (heredofamilial) tremor or a family history of essential tremor. Forty-six patients with manic-depressive illness were given lithium carbonate. Maintenance blood lithium levels were conventional, ranging between 0.6 and l.l mEq/liter. All the patients were examined for essential tremor before therapy. Criteria for the diagnosis of benign essential tremor were: postural hand PSYCHOSOMATICS
tremor since early adulthood, family history of postural tremor, no evidence of other neurological disease (specifically Parkinson's disease or hyperthyroidism).2 Case reports Forty patients with no preexisting essential tremor or family history of tremor did not develop a significant postural tremor with lithium therapy. At lithium levels ranging between 0.5 and 0.8 mEq/liter six patients developed disabling postural tremors. Here is a description of their cases. Case t A 65-year-old banker with severe bipolar manic-depressive illness had had a moderate essential hand tremor, a barely noticeable head tremor, and associated tremulousness of the voice (presumably due to respiratory muscle and larynx involvement 2) since adolescence. He was
self-conscious about the tremor and he customarily postponed signing bank documents until he felt particularly well, when he would always press hard with the pen to mask the tremor. At a blood lithium level of0.6 mEq/liter, the tremor became so severe that he could no longer write or drink from a cup, and his voice became very quavery. This marked exacerbation of the tremor was not significantly ameliorated by 80 mg of propranolol daily,) 40 mg of diazepam daily, or 1200 mg of meprobamate daily,4 and the lithium had to be discontinued. Casel A 45-year-old physician with bipolar manic-depressive illness had had a mild hand tremor and occasional tremulousness of the voice since late adolescence. At maintenance blood lithium levels of 0.6 mEq/liter, his voice became more quavery and his hand tremor exacerbated to the point of interfering with suturing. Blood lithium levels of 0.7 to 0.8 mEq/liter resulted in mild dysarthria, presumably because of exacerbation of an associated tremor of the tongue. s Meprobamate, 1200 mg daily, had some ameliorative effect. Case 3
A 65-year-old man with unipolar mania had had a moderate hand 27
Disabling tremor
tremor since adolescence. Maintenance blood lithium levels of 0.7 mEq/liter produced a conspicuous head tremor, and the hand tremor became so severe that he could no longer feed himself. Propranolol, diazepam, and meprobamate were of no value, and lithium had to be discontinued. Case 4 A 45-year-old surgeon with bipolar
manic-depressive illness developed an intention tremor with maintenance blood lithium levels of 0.7 mEq/liter. The tremor was intensified by tension and became a morbid preoccupation, as it would "act up unpredictably" in surgery. Before lithium therapy he had had no noticeable tremor; however, the family history was positive for essential tremor. Cases 5 and 6 In two men with bipolar depressive illness and mild essential tremor, lithium initially exacerbated the tremor to the point of incapacitation. However, as the lithium attenuated psychotic agitation, the tremor became less disabling; and maintenance treatment with lithium, albeit with a moderate tremor, was preferable to abject psychosis.
If conventional blood lithium levels produce a disabling tremor, our experiences suggest that the patient either had a preexisting benign essential tremor or a family history of essential tremor. Essential tremor is exacerbated even by low blood lithium levels and can be a relative contraindication to treatment with lithium. Essential heredofamilial tremor, a common disorder characterized by tremor of a postural nature, may involve any part of the body but is usually more prominent in the hands and arms.4.5 If the tremor involves the muscles of the larynx, respiration, and tongue, low blood lithium levels may also exacerbate (or produce) voice quavering or dysarthria or both. 2•S Patients often make no mention of their constitutional peculiarity and not infrequently they equate the tremor with "nervousness."s The tremor is transmitted as
Dr. Van Pullen is a staff psychiatrist at the Veterans Administration Hospital, Brentwood, Calif, and associate professor of psychiatry in residence at the University of California. Los Angeles. Reprint requests to Dr. Van PUllen at Brentwood VA Hospital, Los Angeles, CA 90073.
PSYCHOSOMATICS
an autosomal dominant with variable penetrance, and there is no known association between familial tremor and affective illness. 6 Relief with alcohol is rather characteristic. According to some investigators, propranolol has a beneficial effect on essential tremor. 7•S Trials of propranolol dosage of up to 80 mg daily were not useful in three of the patients described, but the dosage may have been too low in these cases.7•S 0
REFERENCES I. Schou M: Lithium in psychiatric therapy and prophylaxis. J Psychiat Res 6:67-95, 1968. 2. Benign essential tremor, editorial. Lancet 2:471-472, 1972. 3. Kirk L, Baastrum PC, Schou M: Propranolol and lithium-induced tremor. Lancet 1:839, 1972: 4. Critchley E: Clinical manifestations of essential tremor. J Neurol Neurosurg Psychiat 35:365-372, 1972. 5. Critchley M: Observations on essential (heredofamilial) tremor. Brain 72:113139,1949. 6. Larsson T, Sjogren T: Essential tremor: A clinical and genetic population study. Acta Psychiat Neurologica Scand, suppl 144:1-173, 1960. 7. Tolosa ES, Loewenson RB: Essential tremor: Treatment with propranolol. Neurology 25:1041-1044,1975. 8. Sweet RD, Blumberg J, Lee JE, et al: Propranolol treatment of essential tremor. Neurology 24:64-67, 1974.
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