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Dun & Bradstreet helps companies improve their business performance through data and insights delivered through our Data Cloud and Live Business Identity. From www.dnb.com, select the country or region where your entity is based from the list in the top right-hand corner and find the information on getting a D-U-N-S Number specifically tailored to your country or region. Return time and cost for each request vary by country.DHS Home >Division of Mental Health and Addiction Services >Major Initiatives >Trauma Informed Care >DMHAS Trauma Informed CareMore InformationI need help ..Trauma TrainingAncora’s CornerWords Matter..Trauma Facts
’In a trauma informed system, trauma is viewed not as a single discrete event, but rather as a defining and organizing experience that forms the core of an individual’s identity. The far reaching impact and the attempts to cope with the aftermath of the traumatic experience come to define who the trauma survivor is.’ (Harris and Fallot, 2001)
The New Jersey Division of Mental Health and Addiction Services (DMHAS) maintains that recovery from trauma is possible, therefore trauma sensitivity shall be a governing principle of DMHAS as we address policy making, service system design and implementation, workforce development, and professional practice.
Trauma-Informed Care in Behavioral Health Services: TIP 57
Click here or on the image to download the brochure.
Quick Guide for Clinicians Based on TIP 57: Trauma-Informed Care in Behavioral Health Services
Click here or on the image to download the brochure.
SAMHSA Guidelines on ’How We Talk About it Matters’ and the Carter Center’s Journalism Resource Guide on Behavioral Health
How does DMHAS define trauma?
Trauma refers to extreme stress that overwhelms an individual’s ability to cope. Individual trauma can result from an event, a series of events, or circumstances that an individual experiences as physically or emotionally harmful or threatening. It is not the objective facts of an event that determines whether that event is traumatic; it is the way in which each individual internalizes the emotional experience of the event. Traumatic events or circumstances often have lasting adverse effects on an individual’s basic sense of self, trust in others, physical, social, emotional, or spiritual well-being.
DMHAS recognizes that staff throughout the system of care is at risk for vicarious traumatization. A culture shift toward a trauma-informed system of care also rests on staff members’ experiences of safety, trustworthiness, choice, collaboration, and empowerment. Staff shall be provided with support, protocols, education and opportunities for training and supervision to maintain wellness and resiliency. (SAMHSA, 2012)
To top
What is a Trauma Informed System of Care?
In a Trauma-informed system, and in recognition that the majority of individuals who seek mental health and substance abuse services have experienced trauma, screening, assessment and trauma sensitive services must be applied universally to every individual. In a trauma-informed system, services are designed to address the needs of trauma survivors. Services must:
*Include individuals and their supporters in the planning, design, implementation and monitoring of best and promising trauma practices.
*Train staff to understand that regardless of the reasons an individual seeks service, staff ask respectfully about trauma history, and are prepared to listen
*Utilize language that is person-centered, which is reinforced through continued training and supervision.
*Include the impact of all types of trauma: disaster, vicarious traumatization, acute, continuous, etc.
*Ensure that leadership develops and disseminates information and technical assistance on best practices.
*Incorporate knowledge about trauma in all aspects of service delivery.
*Ensure that environments are welcoming, hospitable and engaging
*Ensure that service delivery minimizes re-victimization and facilitates wellness, recovery and resiliency.
DMHAS is committed to the development of a trauma informed system of care within our existing wellness and recovery oriented framework for both the state psychiatric hospitals and the community based system. Supervision and training must be implemented to prevent employees from experiencing compassion fatigue and/or vicarious traumatization.
To top
*Values and Guiding Principles
*Trauma Assessment Tools
*Guidelines for Self-Assessment of Staff Competencies
*Comfort Rooms
*Trauma Screening
*DMHAS Blueprint for Action
Trauma-Informed services must be based on principles, policies, and procedures that provide safety, voice and choice, and carried out within every part of a system and/or agency, including administration, and management. The current service delivery system needs to be assessed and modified to incorporate Trauma-Informed principles into practice. (SAMHSA, 2012)
When an organization can say that its culture reflects all of the values above in each contact, physical setting, relationship, and activity; in both the experiences of staff as well as consumers, then the culture is trauma-informed. (Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D.; July, 2009)
Information from Asst. Commissioner Lynn Kovich, December 2014
Values and Guiding Principles for a Trauma Informed System of Care - this document outlines the basic principles that DMHAS has put forth for agencies to use as they create a new, or continue to grow an existing trauma informed and trauma sensitive culture of trauma informed care.
Values and Guiding Principles Slide Show - this PowerPoint show can be used within any agency to assist you in the introduction of cultural changes to staff and service recipients.
To top
Trauma Assessment ToolsFor people with histories of traumatic life events, thorough assessment gathers the information necessary to understand the role and effect of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and any ongoing diagnostic and treatment considerations, including reevaluation or follow-up. These measures are identified as evidence based through SAMHSA and in the Center for Substance Abuse Treatment’s: TREATMENT IMPROVEMENT PROTOCOL 57: Trauma-Informed Care in Behavioral Health Services.
DMHAS position and directions for agencies: Trauma Assessment
Guidelines for Self-Assessment of Staff CompetenciesTrauma champions are the individuals who mentor and coach us through change, mitigate the impact of new direction, and keep us on task and help with problem solving along the way:
’A champion understands the impact of violence and victimization on the lives of people seeking mental health or addiction services and is a front-line worker who thinks ‘trauma first.’ When trying to understand a person’s behavior, the champion will ask, ‘is this related to abuse and violence?’ A champion will also think about whether his or her own behavior is hurtful or insensitive to the needs of a trauma survivor. The champion is there to do an identified job-he is a case manager or a counselor or a residential specialist-but in addition to his or her job, a champion is there to shine the spotlight on trauma issues.’ -Harris & Fallot, 2001.
The New Jersey Department of Human Services, Division of Mental Health & Addiction Services recognizes the national statistics that indicate that Universal Precautions are necessary in all agencies throughout our system (43%-81% of adults in psychiatric hospitals and up to 2/3 of individuals in substance abuse treatment have experienced trauma.) Staff who work with individuals who have trauma have special responsibilities because of the nature of this work whether they are administrative, clinical, supervisory or non-clinical. Assigning a trauma-aware staff member who is committed to trauma informed services, will help agency efforts stay focused and on track.
Information from Assistant Commissioner Lynn Kovich - February, 2015
Guidelines for Conducting an Organization of Self-Assessment of Staff Competencies to provide Trauma-Informed Services - these guidelines will help agencies to conduct a self-assessment of staff competencies to provide trauma-informed services. DMHAS wants you to perform this assessment and keep your results on file as you begin to assign your trauma champions and teams. As you move through each layer of staffing, keep in mind those who you may want to choose as champions for trauma.
To top
A trauma-informed approach can be implemented in any type of service setting or organization to address the consequences of trauma and to facilitate healing. One tool that SAMHSA recommends for all levels of care is Comfort Rooms: a preventive tool recommended by SAMHSA as an alternative to seclusion and restraint. The Comfort Room is a participatory project between agencies and the people they serve, and includes comfort strategies and environmental changes throughout the entire culture of each agency, which ultimately produce culture change and impact throughout our system.
Information from Assistant Commissioner Lynn Kovich - October, 2014
Guidelines for Development of Comfort Rooms - we believe that Comfort Rooms can play a vital role in recovery, and are an integral part of systems that are Trauma Informed. The DMHAS Trauma Informed Care Work Group, along with staff from Essex County Hospital Center have developed guidelines for agencies throughout the system who may want to begin working toward implementing a Comfort Room in their agency.
Comfort Rooms Slide Show - This PowerPoint can be used by agencies to introduce the Comfort Rooms to your staff and service recipients as you look toward creating a more trauma sensitive culture.
To top
Trauma ScreeningBecause universal trauma informed screening can prevent misdiagnosis and inappropriate treatment planning, SAMHSA has put forth, and NJ DMHAS has adopted, the following recommendation:
’All adults and children who enter the system of care, regardless of which ’door’ they enter, should be screened for abuse and trauma at or close to admission..’
Two evidence based screening tools are recommended for use within all DMHAS agencies throughout the system of care. These measures are identified as evidence based through SAMHSA and in the Center for Substance Abuse Treatment’s: TREATMENT IMPROVEMENT PROTOCOL 57: Trauma-Informed Care in Behavioral Health Services.
Information from Assistant Commissioner Lynn Kovich - February, 2015
Division of Mental Health and Addiction Services Trauma Informed Care Universal Screening - Trauma-informed screening is an essential part of the intake evaluation and the treatment planning process. If someone acknowledges a trauma history, further assessment is necessary to determine the extent of trauma-related symptoms. If you are already screening for trauma, using a different evidenced based tool, please continue to use what has been proven as successful for you. If you do not have policy for a formal screening process or tool, please use this documentation to move with us toward being more trauma informed.
To top
The DMHAS blueprint for action has been adapted from the SAMHSA toolkit: Building Trauma-Informed Mental Health Service Systems: Blueprint for Action, which describes a current state behavioral health system and organizational activities that are needed to make the transition to a trauma-informed system with emerging best practices, and trauma-specific services (2004; Ann Jennings, Ph.D.; for NASMHPD, SAMSHA) In a trauma-informed system, services are designed to address the needs of trauma survivors. The New Jersey Department of Human Services/Division of Mental Health and Addiction Services (DHS/DMHAS) agrees with national experts: trauma sensitivity shall be a governing principle in policy making, service system design and implementation, workforce development, and professional practice.
Information from Assistant Commissioner Lynn Kovich - February, 2015
DMHAS Blueprint for Action: Building a Trauma-Informed Behavioral Health Service System for New Jersey - this blueprint describes steps to infuse trauma-informed practices into the New Jersey Mental Health and Addictions system of care and provides specific practices to meet the needs of trauma survivors.
To top
Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Essential Tremor article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.TremorIn this articleInfo Dj Tremor Dnb Homepage Page
See separate related article Abnormal Involuntary Movements.Trending Articles
Tremor may occur as a symptom or sign of an underlying disease or as an exaggerated physiological phenomenon. It is not a diagnostic term. It can be defined as a rhythmic oscillatory movement of a body part, resulting from the contraction of opposing muscle groups.
The vast majority of tremor seen in the primary care setting is due to ’essential tremor’ (ET). This condition has previously been termed as benign or familial essential tremor. The term ’benign’ should be dropped, as although the majority of sufferers do not have significant sequelae as a result of the condition, it can be very troubling and in some cases disabling.Epidemiology of essential tremor
*ET is thought to affect 0.4-6% of the population.[1]
*Men and women are equally affected.
*Approximately 50% of ET cases are familial with autosomal dominant inheritance.
*The onset of familial ET is usually during childhood, whereas sporadic ET usually occurs in those over 40 years of age.[2]Other causes of tremor
*Physiological tremor.
*Exaggerated physiological tremor due to illness, fever, hyperthyroidism, anxiety states, etc.
*Post-traumatic/post-neurosurgical tremor.
*Medication/drug-induced.
*Multiple sclerosis.
*Parkinsonism and Parkinson’s-plus syndromes - eg, multiple system atrophy, progressive supranuclear palsy
*Metabolic derangement - eg, electrolyte disturbance, renal and hepatic failure.
*Wilson’s disease.
*Cerebellar disease.
*Basal ganglia lesions.
*Dystonias.
*Other movement disorders - eg, tardive dyskinesia, cerebrovascular disease.
*Writer’s cramp or tremor.
*Psychogenic tremor.
*Arsenic, heavy metal, organophosphate or industrial solvent poisoning.
*Vitamin deficiency (especially B1).Classification of tremors
Tremors can be initially classified as rest or action tremors.[1] Rest tremors occur when the body part is supported against gravity - eg, hands at rest in one’s lap. Mental stress or general movement makes rest tremors worse. Action tremors are further subdivided into static, postural or kinetic tremors:
*Static - occurs in a relaxed limb when fully supported at rest. Causes include Parkinson’s disease, Parkinsonism, other extrapyramidal diseases and multiple sclerosis.
*Postural - occurs when a part of the body is held in a fixed position against gravity (it can also remain during movement). Types include physiological tremor, exaggerated physiological tremor (eg, thyrotoxicosis), anxiety states, alcohol abuse, drugs (see below), heavy metal poisoning, neurological diseases, Wilson’s disease, neurosyphilis, peripheral neuropathies, essential (familial) tremor and task-specific tremors such as primary writing tremor.
*Kinetic or action tremor - occurs during voluntary active movement of an upper body part. If action tremor worsens as goal-directed movement approaches its intended target, this is intention tremor (indicative of a cerebellar cause). Associated with brainstem or cerebellar disease, including multiple sclerosis, spinocerebellar degenerations, vascular disease and tumours.Presentation
It is often described by sufferers as a trembling or quivering movement or sensation.Symptoms
*Essential tremor (ET):
*This is usually a distal symmetrical postural tremor of the upper limbs, usually of low amplitude with a fairly rapid frequency of 8-10 Hz.
*It may initially be transient but usually progresses to become persistent.
*The neck muscles may be involved, causing tremor of the head (about 40% of cases). Voice, face and jaw muscles may be involved.[3]
*Frequency of the tremor tends to remain constant but amplitude is highly variable depending on emotional and physiological state.
*Background tremor amplitude tends to progress over the course of years.
*Some degree of control over the tremor, exerted by concentration on a task or via execution of a skilled manual repertoire, is common.
*Tremor does not occur during sleep.
*Most report improvement of tremor following alcohol ingestion.
*It may be difficult to distinguish from exaggerated physiological tremor, that caused by hyperthyroidism/fever or tremor due to medications; these causes should always be borne in mind before diagnosing ET.
*Physiological tremor:
*Can occur in a state of normality or in an exaggerated form, due to a precipitant such as anxiety, hyperthyroidism, hypoglycaemia, caffeine excess, fever, medication, etc.
*It is usually associated with certain postures.
*It is usually bilateral, symmetrical and non-progressive over time.
*There may be a family history but this is less often than in ET.
*Other motor symptoms should not accompany the tremor.
*Secondary tremors due to neurological disease:
*Individual presentation is highly variable depending on the underlying cause. Enquire about symptoms of specific diseases such as Parkinsonism, dystonias, cerebellar syndrome, symptoms in other parts of the body, constitutional symptoms and problems with gait and balance. Tremor is not usually the only motor symptom.
*More than 70% of patients with Parkinson’s disease have tremor as the presenting feature. This tremor is typically asymmetrical, occurs at rest and becomes less prominent with voluntary movement.
*Psychogenic tremors are usually characterised by an abrupt onset, spontaneous remission, changing tremor characteristics and absence during distraction.[4]
*Tremor may be worsened by lithium, antidepressants, bronchodilators, neuroleptics, amiodarone, procainamide, prednisolone, cinnarizine, ciclosporin, metoclopramide, methylphenidate and sodium valproate, caffeine (or other stimulants), sympathomimetics (eg, salbutamol, L-dopa and associated anti-Parkinsonian drugs), theophylline, thyroid h
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Dun & Bradstreet helps companies improve their business performance through data and insights delivered through our Data Cloud and Live Business Identity. From www.dnb.com, select the country or region where your entity is based from the list in the top right-hand corner and find the information on getting a D-U-N-S Number specifically tailored to your country or region. Return time and cost for each request vary by country.DHS Home >Division of Mental Health and Addiction Services >Major Initiatives >Trauma Informed Care >DMHAS Trauma Informed CareMore InformationI need help ..Trauma TrainingAncora’s CornerWords Matter..Trauma Facts
’In a trauma informed system, trauma is viewed not as a single discrete event, but rather as a defining and organizing experience that forms the core of an individual’s identity. The far reaching impact and the attempts to cope with the aftermath of the traumatic experience come to define who the trauma survivor is.’ (Harris and Fallot, 2001)
The New Jersey Division of Mental Health and Addiction Services (DMHAS) maintains that recovery from trauma is possible, therefore trauma sensitivity shall be a governing principle of DMHAS as we address policy making, service system design and implementation, workforce development, and professional practice.
Trauma-Informed Care in Behavioral Health Services: TIP 57
Click here or on the image to download the brochure.
Quick Guide for Clinicians Based on TIP 57: Trauma-Informed Care in Behavioral Health Services
Click here or on the image to download the brochure.
SAMHSA Guidelines on ’How We Talk About it Matters’ and the Carter Center’s Journalism Resource Guide on Behavioral Health
How does DMHAS define trauma?
Trauma refers to extreme stress that overwhelms an individual’s ability to cope. Individual trauma can result from an event, a series of events, or circumstances that an individual experiences as physically or emotionally harmful or threatening. It is not the objective facts of an event that determines whether that event is traumatic; it is the way in which each individual internalizes the emotional experience of the event. Traumatic events or circumstances often have lasting adverse effects on an individual’s basic sense of self, trust in others, physical, social, emotional, or spiritual well-being.
DMHAS recognizes that staff throughout the system of care is at risk for vicarious traumatization. A culture shift toward a trauma-informed system of care also rests on staff members’ experiences of safety, trustworthiness, choice, collaboration, and empowerment. Staff shall be provided with support, protocols, education and opportunities for training and supervision to maintain wellness and resiliency. (SAMHSA, 2012)
To top
What is a Trauma Informed System of Care?
In a Trauma-informed system, and in recognition that the majority of individuals who seek mental health and substance abuse services have experienced trauma, screening, assessment and trauma sensitive services must be applied universally to every individual. In a trauma-informed system, services are designed to address the needs of trauma survivors. Services must:
*Include individuals and their supporters in the planning, design, implementation and monitoring of best and promising trauma practices.
*Train staff to understand that regardless of the reasons an individual seeks service, staff ask respectfully about trauma history, and are prepared to listen
*Utilize language that is person-centered, which is reinforced through continued training and supervision.
*Include the impact of all types of trauma: disaster, vicarious traumatization, acute, continuous, etc.
*Ensure that leadership develops and disseminates information and technical assistance on best practices.
*Incorporate knowledge about trauma in all aspects of service delivery.
*Ensure that environments are welcoming, hospitable and engaging
*Ensure that service delivery minimizes re-victimization and facilitates wellness, recovery and resiliency.
DMHAS is committed to the development of a trauma informed system of care within our existing wellness and recovery oriented framework for both the state psychiatric hospitals and the community based system. Supervision and training must be implemented to prevent employees from experiencing compassion fatigue and/or vicarious traumatization.
To top
*Values and Guiding Principles
*Trauma Assessment Tools
*Guidelines for Self-Assessment of Staff Competencies
*Comfort Rooms
*Trauma Screening
*DMHAS Blueprint for Action
Trauma-Informed services must be based on principles, policies, and procedures that provide safety, voice and choice, and carried out within every part of a system and/or agency, including administration, and management. The current service delivery system needs to be assessed and modified to incorporate Trauma-Informed principles into practice. (SAMHSA, 2012)
When an organization can say that its culture reflects all of the values above in each contact, physical setting, relationship, and activity; in both the experiences of staff as well as consumers, then the culture is trauma-informed. (Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D.; July, 2009)
Information from Asst. Commissioner Lynn Kovich, December 2014
Values and Guiding Principles for a Trauma Informed System of Care - this document outlines the basic principles that DMHAS has put forth for agencies to use as they create a new, or continue to grow an existing trauma informed and trauma sensitive culture of trauma informed care.
Values and Guiding Principles Slide Show - this PowerPoint show can be used within any agency to assist you in the introduction of cultural changes to staff and service recipients.
To top
Trauma Assessment ToolsFor people with histories of traumatic life events, thorough assessment gathers the information necessary to understand the role and effect of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and any ongoing diagnostic and treatment considerations, including reevaluation or follow-up. These measures are identified as evidence based through SAMHSA and in the Center for Substance Abuse Treatment’s: TREATMENT IMPROVEMENT PROTOCOL 57: Trauma-Informed Care in Behavioral Health Services.
DMHAS position and directions for agencies: Trauma Assessment
Guidelines for Self-Assessment of Staff CompetenciesTrauma champions are the individuals who mentor and coach us through change, mitigate the impact of new direction, and keep us on task and help with problem solving along the way:
’A champion understands the impact of violence and victimization on the lives of people seeking mental health or addiction services and is a front-line worker who thinks ‘trauma first.’ When trying to understand a person’s behavior, the champion will ask, ‘is this related to abuse and violence?’ A champion will also think about whether his or her own behavior is hurtful or insensitive to the needs of a trauma survivor. The champion is there to do an identified job-he is a case manager or a counselor or a residential specialist-but in addition to his or her job, a champion is there to shine the spotlight on trauma issues.’ -Harris & Fallot, 2001.
The New Jersey Department of Human Services, Division of Mental Health & Addiction Services recognizes the national statistics that indicate that Universal Precautions are necessary in all agencies throughout our system (43%-81% of adults in psychiatric hospitals and up to 2/3 of individuals in substance abuse treatment have experienced trauma.) Staff who work with individuals who have trauma have special responsibilities because of the nature of this work whether they are administrative, clinical, supervisory or non-clinical. Assigning a trauma-aware staff member who is committed to trauma informed services, will help agency efforts stay focused and on track.
Information from Assistant Commissioner Lynn Kovich - February, 2015
Guidelines for Conducting an Organization of Self-Assessment of Staff Competencies to provide Trauma-Informed Services - these guidelines will help agencies to conduct a self-assessment of staff competencies to provide trauma-informed services. DMHAS wants you to perform this assessment and keep your results on file as you begin to assign your trauma champions and teams. As you move through each layer of staffing, keep in mind those who you may want to choose as champions for trauma.
To top
A trauma-informed approach can be implemented in any type of service setting or organization to address the consequences of trauma and to facilitate healing. One tool that SAMHSA recommends for all levels of care is Comfort Rooms: a preventive tool recommended by SAMHSA as an alternative to seclusion and restraint. The Comfort Room is a participatory project between agencies and the people they serve, and includes comfort strategies and environmental changes throughout the entire culture of each agency, which ultimately produce culture change and impact throughout our system.
Information from Assistant Commissioner Lynn Kovich - October, 2014
Guidelines for Development of Comfort Rooms - we believe that Comfort Rooms can play a vital role in recovery, and are an integral part of systems that are Trauma Informed. The DMHAS Trauma Informed Care Work Group, along with staff from Essex County Hospital Center have developed guidelines for agencies throughout the system who may want to begin working toward implementing a Comfort Room in their agency.
Comfort Rooms Slide Show - This PowerPoint can be used by agencies to introduce the Comfort Rooms to your staff and service recipients as you look toward creating a more trauma sensitive culture.
To top
Trauma ScreeningBecause universal trauma informed screening can prevent misdiagnosis and inappropriate treatment planning, SAMHSA has put forth, and NJ DMHAS has adopted, the following recommendation:
’All adults and children who enter the system of care, regardless of which ’door’ they enter, should be screened for abuse and trauma at or close to admission..’
Two evidence based screening tools are recommended for use within all DMHAS agencies throughout the system of care. These measures are identified as evidence based through SAMHSA and in the Center for Substance Abuse Treatment’s: TREATMENT IMPROVEMENT PROTOCOL 57: Trauma-Informed Care in Behavioral Health Services.
Information from Assistant Commissioner Lynn Kovich - February, 2015
Division of Mental Health and Addiction Services Trauma Informed Care Universal Screening - Trauma-informed screening is an essential part of the intake evaluation and the treatment planning process. If someone acknowledges a trauma history, further assessment is necessary to determine the extent of trauma-related symptoms. If you are already screening for trauma, using a different evidenced based tool, please continue to use what has been proven as successful for you. If you do not have policy for a formal screening process or tool, please use this documentation to move with us toward being more trauma informed.
To top
The DMHAS blueprint for action has been adapted from the SAMHSA toolkit: Building Trauma-Informed Mental Health Service Systems: Blueprint for Action, which describes a current state behavioral health system and organizational activities that are needed to make the transition to a trauma-informed system with emerging best practices, and trauma-specific services (2004; Ann Jennings, Ph.D.; for NASMHPD, SAMSHA) In a trauma-informed system, services are designed to address the needs of trauma survivors. The New Jersey Department of Human Services/Division of Mental Health and Addiction Services (DHS/DMHAS) agrees with national experts: trauma sensitivity shall be a governing principle in policy making, service system design and implementation, workforce development, and professional practice.
Information from Assistant Commissioner Lynn Kovich - February, 2015
DMHAS Blueprint for Action: Building a Trauma-Informed Behavioral Health Service System for New Jersey - this blueprint describes steps to infuse trauma-informed practices into the New Jersey Mental Health and Addictions system of care and provides specific practices to meet the needs of trauma survivors.
To top
Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Essential Tremor article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.TremorIn this articleInfo Dj Tremor Dnb Homepage Page
See separate related article Abnormal Involuntary Movements.Trending Articles
Tremor may occur as a symptom or sign of an underlying disease or as an exaggerated physiological phenomenon. It is not a diagnostic term. It can be defined as a rhythmic oscillatory movement of a body part, resulting from the contraction of opposing muscle groups.
The vast majority of tremor seen in the primary care setting is due to ’essential tremor’ (ET). This condition has previously been termed as benign or familial essential tremor. The term ’benign’ should be dropped, as although the majority of sufferers do not have significant sequelae as a result of the condition, it can be very troubling and in some cases disabling.Epidemiology of essential tremor
*ET is thought to affect 0.4-6% of the population.[1]
*Men and women are equally affected.
*Approximately 50% of ET cases are familial with autosomal dominant inheritance.
*The onset of familial ET is usually during childhood, whereas sporadic ET usually occurs in those over 40 years of age.[2]Other causes of tremor
*Physiological tremor.
*Exaggerated physiological tremor due to illness, fever, hyperthyroidism, anxiety states, etc.
*Post-traumatic/post-neurosurgical tremor.
*Medication/drug-induced.
*Multiple sclerosis.
*Parkinsonism and Parkinson’s-plus syndromes - eg, multiple system atrophy, progressive supranuclear palsy
*Metabolic derangement - eg, electrolyte disturbance, renal and hepatic failure.
*Wilson’s disease.
*Cerebellar disease.
*Basal ganglia lesions.
*Dystonias.
*Other movement disorders - eg, tardive dyskinesia, cerebrovascular disease.
*Writer’s cramp or tremor.
*Psychogenic tremor.
*Arsenic, heavy metal, organophosphate or industrial solvent poisoning.
*Vitamin deficiency (especially B1).Classification of tremors
Tremors can be initially classified as rest or action tremors.[1] Rest tremors occur when the body part is supported against gravity - eg, hands at rest in one’s lap. Mental stress or general movement makes rest tremors worse. Action tremors are further subdivided into static, postural or kinetic tremors:
*Static - occurs in a relaxed limb when fully supported at rest. Causes include Parkinson’s disease, Parkinsonism, other extrapyramidal diseases and multiple sclerosis.
*Postural - occurs when a part of the body is held in a fixed position against gravity (it can also remain during movement). Types include physiological tremor, exaggerated physiological tremor (eg, thyrotoxicosis), anxiety states, alcohol abuse, drugs (see below), heavy metal poisoning, neurological diseases, Wilson’s disease, neurosyphilis, peripheral neuropathies, essential (familial) tremor and task-specific tremors such as primary writing tremor.
*Kinetic or action tremor - occurs during voluntary active movement of an upper body part. If action tremor worsens as goal-directed movement approaches its intended target, this is intention tremor (indicative of a cerebellar cause). Associated with brainstem or cerebellar disease, including multiple sclerosis, spinocerebellar degenerations, vascular disease and tumours.Presentation
It is often described by sufferers as a trembling or quivering movement or sensation.Symptoms
*Essential tremor (ET):
*This is usually a distal symmetrical postural tremor of the upper limbs, usually of low amplitude with a fairly rapid frequency of 8-10 Hz.
*It may initially be transient but usually progresses to become persistent.
*The neck muscles may be involved, causing tremor of the head (about 40% of cases). Voice, face and jaw muscles may be involved.[3]
*Frequency of the tremor tends to remain constant but amplitude is highly variable depending on emotional and physiological state.
*Background tremor amplitude tends to progress over the course of years.
*Some degree of control over the tremor, exerted by concentration on a task or via execution of a skilled manual repertoire, is common.
*Tremor does not occur during sleep.
*Most report improvement of tremor following alcohol ingestion.
*It may be difficult to distinguish from exaggerated physiological tremor, that caused by hyperthyroidism/fever or tremor due to medications; these causes should always be borne in mind before diagnosing ET.
*Physiological tremor:
*Can occur in a state of normality or in an exaggerated form, due to a precipitant such as anxiety, hyperthyroidism, hypoglycaemia, caffeine excess, fever, medication, etc.
*It is usually associated with certain postures.
*It is usually bilateral, symmetrical and non-progressive over time.
*There may be a family history but this is less often than in ET.
*Other motor symptoms should not accompany the tremor.
*Secondary tremors due to neurological disease:
*Individual presentation is highly variable depending on the underlying cause. Enquire about symptoms of specific diseases such as Parkinsonism, dystonias, cerebellar syndrome, symptoms in other parts of the body, constitutional symptoms and problems with gait and balance. Tremor is not usually the only motor symptom.
*More than 70% of patients with Parkinson’s disease have tremor as the presenting feature. This tremor is typically asymmetrical, occurs at rest and becomes less prominent with voluntary movement.
*Psychogenic tremors are usually characterised by an abrupt onset, spontaneous remission, changing tremor characteristics and absence during distraction.[4]
*Tremor may be worsened by lithium, antidepressants, bronchodilators, neuroleptics, amiodarone, procainamide, prednisolone, cinnarizine, ciclosporin, metoclopramide, methylphenidate and sodium valproate, caffeine (or other stimulants), sympathomimetics (eg, salbutamol, L-dopa and associated anti-Parkinsonian drugs), theophylline, thyroid h
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