I need information to help a friend of mine.  About 2 months ago she
starting experience severe tremors - her arms and legs shaking
visibly.  She also began stuttering when speaking, extremely badly ...
t-t-t-t-t-t-t-t-t-t-t-t-a-l-k-k-k-k-k-k-innnnnnng-g-g-g-g-g-g-g-g-g-g-g-g
like that... nearly unable to communicate.  Her speach patterns are
reminiscent of another friend who experienced sever brain damage in a
accident.  But the friend in question has experienced no know physical
trauma, and she had never exhibited such symptoms previously.

Additionally she has also experienced intense insomia, in fact the
insomnia started a month or two before the shaking/stuttering.  Also
she has had a history of anorexia, which had been fairly bad just
prior to the insomnia... in fact she came out a treatment center for
anorexia just prior to the insomnia starting.

She has been basically disabled for the past couple months or so
because of this- unable to speak, work, etc.  She has had an MRI but
it showed nothing abnormal.  Her doctor has indicated that he thinks
it is something psychological. Having viewed the condition first hand
I find it hard to believe that it could be psychological.

I want to find information to help her diagnose and overcome this
situation.  What sorts of things might cause extreme shaking and
extreme stuttering?  Is there a real possibility for psychological
conditions to cause?  Is there an known relationship between
stuttering/tremors and insomnia, or between stuttering/tremors and
anorexia?  Another interesting fact is that her tremors/stuttoring
stopped during a trip out of town and immediately returned when she
cam home... is it possible that this is being cause by some sort of
allergic reaction, or perhaps some kind of poisoning - carbon monoxide
or something of that sort.

I'm very concerned about her and thank you so much for you help.

tphoenix...

I have a background of 25+ years in the field of mental health,
and will speak primarily from that.

There are any number of psychological disorders which tend to
overlap and thus require extensive evaluation by a psychiatric
professional before a diagnosis is made. Also realize that such
a diagnosis is essentially an educated guess - a working 
hypothesis which is subject to change as more information is
made available.

Anorexia itself is usually a symptom of a deeper disorder, and
the fact that your friend recently left a treatment center is
unlikely a coincidence. It's quite possible that, in addressing
the anorexic behaviors, issues were brought to the surface but
insufficiently resolved, and, since the anorexic behavior was
discouraged, other symptoms have arisen to take its place.

Given her history of anorexia, and the lack of evidence of a
physical cause in the MRI, the doctor is quite correct to 
suspect what he would call a somatoform disorder, in which 
psychological conflicts can be translated into physical
problems and complaints:
http://www.psyweb.com/Mdisord/somatd.html

In general, depression of some type is a common partner with
anorexia, which is also commonly associated with a Body 
Dysmorphic Disorder, a variation of somatoform disorder.

General Anxiety Disorder can be associated with insomnia.

A more specific disorder which combines depression with 
multiple possible symptoms including shaking, trembling,
stuttering, palpitations, sweating and blushing is called
Social Anxiety Disorder.

See page 72 of 96 of this PDF file, hosted on the site of the
University of North Carolina at Chapel Hill School of Public 
Health, titled 'YOUTH SUICIDE, MOOD DISORDERS, ANXIETY DISORDERS,
AND ADHD', by RICHARD WEISLER, MD:
http://www.sph.unc.edu/oce/school_ho/mental3.pdf

That entire document will provide a considerable education
of the interrelationship between anorexia, insomnia, anxiety,
depression, and the other symptoms you mentioned.

Also note the illustration on page 75, titled:
"Missed Opportunity for Treatment*:
 195 Patients with Generalized Social Anxiety Disorder
 Only 0.5% WERE TREATED
 Katzelnick D, et al. Presented at 37th Annual Meeting
 of the American College of Neuropsychopharmacology;
 December 14-18, 1998; Los Croabas, Puerto Rico.
 *Diagnosis codes reviewed over the past year"


That this is psychological and not physical in nature is
made more plausible by the absence of symptoms during your
excursion out of town. Social anxiety is exacerbated by
familiar situations in which familiar stressors are known
to exist. Leaving town for an unknown environment can 
actually relieve this to a degree.

A true neurological condition would be much less likely
to evaporate in this manner.


My immediate response, if I was her, would be to make
contact with the anorexia clinic. Re-admission might 
be in order, given the complications that have surfaced
following her departure. They may have a record of her
recent progress and status at departure, and this change
of symptoms may be related, as I said, to unresolved
issues which were suspected but not confirmed prior to
her departure. Additionally, they may have added or 
removed medications from her regime, the effects of 
which changes they didn't have time to observe prior
to her departure. Changes in medications can bring 
about radical changes in the symptoms of anxiety and
depression related disorders.

If she is highly resistant to returning to the clinic,
this in itself may be telling, as she may have known
that they were "on to something" just prior to her
departure, and she may have hidden it from them and
managed to leave before she was discovered.

If she cannot be convinced to return to clinic, at 
the least she should seek assistance from a psychiatric
professional, rather than simply a medical doctor, and
should make her records from the anorexia clinic available
to this professional.

Anorexia is a severe symptom normally associated with
a slew of symptoms inclucing anxiety, depression, poor
self-image, low self-esteem, and possibly related to
issues like verbal, emotional, physical or sexual abuse
during childhood. Suicidal feelings and ideation are a
real concern, and a person who is suffering from it
should be given consistent treatment of the most 
effective kind possible.

I realize that you'd much prefer this to be a physical
condition with a fairly straightforward physical solution.
Unfortunately, this is very unlikely, with the singular
exception that a change in medications could have been
a significant contributor to what she is experiencing.

Well, also the fact that insomnia can lead to a shortage
of REM sleep, or dream sleep, or recuperative sleep, and
can lead to hallucinations even in a "normal" person with
no known psychological issues. Naturally this could cause
a major exacerbation of whatever psychological problems
exist in addition.


Please do not rate this answer until you are satisfied that  
the answer cannot be improved upon by way of a dialog  
established through the "Request for Clarification" process. 
 
A user's guide on this topic is on skermit-ga's site, here: 
http://www.christopherwu.net/google_answers/answer_guide.html#how_clarify 
 
sublime1-ga


Searches done, via Google:

anorexia insomnia shaking stuttering
://www.google.com/search?q=anorexia+insomnia+shaking+stuttering

somatoform
://www.google.com/search?q=somatoform

---

Request for Answer Clarification by tphoenix-ga on 04 Feb 2006 09:16 PST

>>Please do not rate this answer until you are satisfied that  
the answer cannot be improved upon by way of a dialog  
established through the "Request for Clarification" process.

Dear Submlime1,

Thanks very much for your very insightful answer!  You've written well
and informatively and given me an increased understanding of the
plausibility and in fact likelihood of a psychological cause.  I'm
happy with your answer and am happy to pay the agreed rate based on
it.  However, since you did include the above sentence I will follow
up:

In addition to establishing whether or not a psychological solution is
plausible, I had also wished to know what other non-psychological
conditions might lead to her symptoms.  You've made a good point
regarding her improving when leaving town, which might explain it. 
However the reason I asked about carbon monoxide or some other type of
poisoning as an alternative explanation is that a mutual friend
visited for several days to help her and stayed at her condo.  The
entire time she was at her condo she felt sick, flu like symptoms...
immediately upon leaving she felt better.  Also the other night I
visited for a few hours and felt sick to my stomach while there.  Thus
I wonder if something environmental is at play.

Finally from the neurological disorder perspective, I was very
relieved to learn that her MRI was negative... but I do not personally
know how all-encompassing an MRI is.  I know that neurologists often
perform a battery of tests not just an MRI, so apparently an MRI can't
detect everything.  However her G.P. has not sent her to a
neurologist, feeling it's not necessary.  From my perspective one
would want to send her to a neurologist and through a battery of tests
if only to conclusively prove that there is nothing neurologically to
worry about.

---

Clarification of Answer by sublime1-ga on 04 Feb 2006 12:01 PST

tphoenix...

I understand your interest in considering all possibilities.

While the fact that you and another person experienced flu-like
symptoms at her condo, which could indicate some kind of an
environmental toxicity, you should also realize that sensitive
people can sometimes experience the pain of someone who is in
the throes of physical and/or psychological suffering. I was
able to observe this phemomenon quite commonly, both in myself
and certain co-workers in the field of mental health, when
engaging with certain clients who were subject to severe
suffering. There were often situations in which the staff
were more in touch with the suffering than the client, which
is one reason the client had difficulty healing. One must be
able to experience one's pain before it can be healed.

Nonetheless, a carbon monoxide (CO) detector is a device which
is readily available and can be installed for safety. You don't
say whether there is a device in her condo, such as a wood-burning
stove, which would justify your suspicion of CO toxicity, but
a detector can certainly allay or confirm your suspicions:
http://www.codetection.com/

However, the symptoms of CO poisoning don't mesh well with
stuttering, trembling or shaking:
http://www.carbon-monoxide-poisoning.com/symptoms.html


As for other neurological possibilities, this is not my area
of expertise, but research indicates that similar symptoms
could be caused by other things, and detected by way of a
thorough neurological exam.

One such condition is manganese poisoning, which someone 
who works with clays and glazes might be exposed to, and
which can cause the following symptoms:

-nervousness
-irritability
-memory loss
-tiredness
-insomnia
-muscle weakness
-muscle pain
-trembling fingers
-stiffness of limbs
-difficulty with fine movements
-stuttering
-hoarse voice
-urinary problems
-impotence
http://www.claystation.com/technical/techarticles/submittedarticles.html


I also found, on a neurology forum, a question by a woman with
some similar symptoms. The answer by the neurologist may interest
you. Her symptoms were:

"I have been having the following symptoms for about one
 and a half years: severe anxiety, insomnia, shaking, muscle
 twitching, feeling constantly like I am in a bad "fog",
 short-term memory problems, trouble articulating thoughts,
 trouble speaking clearly, stuttering, an extreme jittery
 feeling throughout my body, 24 hours a day, pounding
 heartbeat, weird vision problems and palpitations."
http://209.51.172.19/forums/neuro/archive/3004.html


Also, let me remind you that changes in medication can 
produce symptoms similar to hers, especially those that
produce an increase in serotonin levels in the brain,
such as adding Prozac to her regimen. Too much serotonin
can produce symptoms such as:

"...violent trembling, profuse sweating, insomnia, nausea,
 teeth chattering, chilling, shivering, aggressiveness,
 over-confidence, agitation, and malignant hyperthermia."
http://www.mental-health-matters.com/articles/article.php?artID=160

So I would definitely pursue an awareness of what changes were
made to your friend's medications at the anorexia clinic.


I hope that sufficiently expands on the information I provided
earlier, but if you have further questions, feel free to ask.

sublime1-ga


Additional searches done, via Google:

CO detector
://www.google.com/search?q=CO+detector

"CO OR carbon monoxide poisoning"
://www.google.com/search?q=%22CO+OR+carbon+monoxide+poisoning%22

neurological +insomnia +"shaking OR trembling" +stuttering
://www.google.com/search?q=neurological+%2Binsomnia+%2B%22shaking+OR+trembling%22+%2Bstuttering

Great insights both from personal experience and research.  Thanks for
all of your help!!