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Shaking or trembling of the hands or other parts of the body are common physical symptoms associated with social anxiety disorder (SAD) and other anxiety conditions.

“Anxiety is a complex mind-body experience involving both emotional and physical responses. A common physical manifestation of anxiety is shaking or trembling,” says Mona Potter, MD, the chief medical officer of InStride Health.

It is caused by the body’s stress response, which triggers the release of hormones such as cortisol and adrenaline. This increases physical tension and contributes to shaking and trembling.

Feeling a lack of control over your body can not only increase the intensity of your shaking, but may also worsen other anxiety-related symptoms. This uncomfortable symptom may also be present in other anxiety disorders, such as panic disorder, specific phobias, and agoraphobia.

If you are experiencing shaking or trembling because of social anxiety disorder and/or another anxiety disorder, know that many treatment options are available.

What Causes Anxiety Shaking?

“Trembling happens when the sympathetic nervous system is activated; this is known as the “fight, flight, freeze” response,” explains Kathryn Boger, PhD, ABPP, the chief clinical officer of InStride Health.

Experiencing anxiety can trigger your body to go into fight-or-flight mode—an evolutionary response meant to keep you safe in times of perceived danger. This physiological response to threats in the environment increases your alertness and prepares your body to take immediate action.

Boger explains that when people feel anxious, the body prepares to deal with the problem by releasing stress hormones such as adrenaline and cortisol into the bloodstream. This results in heightened alertness as well as physical changes, such as increased muscle tension and nerve activity, as well as increased heart rate, blood pressure, and blood flow to your muscles.

This may then lead to the rapid contraction and relaxation of muscles, leading to a shaking, trembling sensation throughout the body, including the hands, legs, and voice.

While this might be uncomfortable or disconcerting when it happens, Boger says that it is both a natural and harmless response to stress.

What Triggers Anxiety Shaking?

Anxiety-related shaking can be triggered by various circumstances. You may notice tremors or shakiness when you are:

• Anticipating an upcoming social interaction
• Attending parties or other social gatherings
• Eating or drinking in public
• Going on a date
• Joining a group conversation already in progress
• Making phone calls
• Meeting new people
• Performing on stage
• Speaking up in a meeting

Potter notes that certain factors may cause people to be more susceptible to shaking when anxious. A genetic predisposition to anxiety and a more sensitive sympathetic nervous system may intensify a person’s fight-or-flight response.

Other factors contributing to shaking when anxious include underlying health conditions, high stress levels, poor sleep patterns, and excess caffeine intake. Some medications may also cause shaking as a side effect, she says. 

Anxiety shaking is one of the physical symptoms associated with anxiety disorders. While this symptom often occurs with conditions such as social anxiety disorder and panic disorder, it can also happen with other conditions such as post-traumatic stress disorder. 

People can also experience this symptom when feeling anxious, even if they do not have a diagnosed anxiety condition. For example, you might shake during a presentation at work or a performance for school. While it can be unsettling, having this symptom does not necessarily mean that you have an anxiety disorder.

Impact of Anxiety Shaking

Shaking caused by social anxiety and other types of anxiety disorders can take a serious toll on a person’s well-being. For some, high levels of stress and exhaustion may intensify tremors.

Shaking and other symptoms can also create a vicious cycle. Feeling fearful or thinking about being embarrassed about shaking in public can also lead to even more shaking, either in the moment or in anticipation of it.

Because people fear shaking and other anxiety symptoms, they engage in avoidance coping to minimize the risk they experience such symptoms. This can lead to the avoidance of situations that trigger anxiety. While this may offer momentary or short-term relief, the reality is that avoidance worsens and prolongs anxiety symptoms.

Treatment for Anxiety Shaking

Anxiety-induced shaking or tremors, otherwise known as psychogenic tremors, are generally treated with psychotherapy, medication, or a combination of both. Which treatment option you choose is completely up to you and what you feel comfortable with.

Speaking with your doctor, psychiatrist, and/or therapist can help you make an informed decision about your treatment.

Psychotherapy

Talk therapies such as cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) may be effective treatment options for some experiencing shaking, tremors, and other symptoms associated with anxiety disorders.

Exposure therapy can be a highly effective treatment for anxiety disorders. In this approach, people are gradually exposed to situations that trigger symptoms of anxiety. Over time, the anxiety response slowly fades.

Medications

Some medications may help reduce or alleviate shaking and tremors, as well as other anxiety-related symptoms. Keep in mind that medications may not work for everyone, and it’s best to speak with your doctor about the most appropriate course of action for your unique needs.

“If the physical symptoms of anxiety are debilitating and significantly impairing, you can talk to your doctor about potential short-term medication options to take the edge off the symptoms as you work on longer-term strategies for managing the symptoms,” Potter says.

• Antidepressants: These medications are typically the first line of treatment. Paxil (paroxetine), Zoloft (sertraline), Luvox (fluvoxamine), and Effexor XR (venlafaxine extended-release) are FDA-approved for treating SAD.
• Benzodiazepines: Medications like Klonopin (clonazepam), Valium (diazepam), and Xanax (alprazolam) can begin working right away to reduce symptoms associated with anxiety, including shaking. However, the risk of dependence increases the longer you stay on these medications.
• Beta-blockers: By blocking the effect of adrenaline, beta-blockers such as Inderal (propranolol) can be used to cope with infrequent anxiety-provoking situations, such as speeches or performances. They are also able to help some individuals reduce tremors.

Coping with Anxiety Shaking

There are many coping methods you can try that may reduce the symptoms associated with social anxiety disorder, especially shaking and tremors. These techniques may be used in addition to psychotherapy and/or medication.

Keep in mind that, in general, most people out and about are likely not noticing your shaking or trembling, and are definitely less focused on it than you are.

Practice Tolerating Distress

Potter suggests that learning to sit with your anxiety symptoms can be helpful. Anxiety is a natural response, she explains, and learning that it is okay to have physical symptoms of anxiety is important.

Exercise Regularly

Physical activity is a natural anxiety reliever. Exercise releases endorphins and decreases cortisol, resulting in stress hormone reduction and an increase in natural mood boosters. Research has found that exercise can significantly reduce symptoms of anxiety and may have a protective effect.

Avoid Certain Substances

An overabundance of substances like alcohol, caffeine, and nicotine may intensify anxiety-related symptoms, including shaking.

“Stimulants like caffeine and nicotine can exacerbate anxiety symptoms, including shaking. Reducing or eliminating their consumption can lead to a decrease in physical manifestations of anxiety,” Potter explains.

Practice Relaxation Techniques

When practiced regularly, relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing may help you feel more grounded and may reduce anxiety-related symptoms such as shaking.

Boger says that mindfulness and meditation practices can help people become more aware of their thoughts and feelings. With regular practice, these techniques can help reduce anxiety symptoms and improve emotional regulation.

Combining these practices with yoga can be particularly helpful. Research indicates that yoga, especially Hatha yoga, effectively reduces anxiety-related symptoms in various anxiety disorders, including social anxiety disorder.

Anna O., aka Bertha Pappenheim, was the pseudonym given to one of the patients of physician Josef Breuer. Her case was described in the book that Breuer wrote with Sigmund Freud, Studies on Hysteria.

Bertha Pappenheim (February 27, 1859 – May 28, 1936) was her real name, and she had initially sought Breuer’s help with a series of symptoms that included visual disturbances, hallucinations, partial paralysis, and speech problems. Breuer diagnosed the young woman with hysteria and later discussed her case with Freud, who developed his own ideas of what lay at the root of Anna O.’s condition.

Her treatment played an important role in the establishment and development of psychoanalysis.

Anna O’s Significance in Psychology

Bertha Pappenheim, referred to as Anna O. in the case history, came to Josef Breuer for treatment for what was then known as hysteria.

While Freud never actually saw her as a patient, her case had a significant impact on the development of psychoanalysis. Freud was fascinated with her case and consulted with Breuer during her treatment.

Anna O.’s Symptoms

While caring for her dying father, Pappenheim experienced a range of symptoms, including:

• Partial paralysis
• Blurred vision
• Headaches
• Hallucinations
• Mood swings
• Eating disorders
• Amnesia
• Facial pain
• Language aphasia

Impact on Freud

While Freud never actually met Pappenheim, her story fascinated him and served as the basis for Studies on Hysteria (1895), a book co-written by Breuer and Freud. Breuer’s description of her treatment led Freud to conclude that hysteria was rooted in childhood sexual abuse.

Freud’s insistence on sexuality as a cause eventually led to a rift with Breuer, who did not share this view on the origination of hysteria. “The plunging into sexuality in theory and practice is not to my taste,” Breuer explained. While the friendship and collaboration soon ended, Freud would continue his work in the development of talk therapy as a treatment for mental illness.

Freud himself once described Anna O. as the true founder of the psychoanalytic approach to mental health treatment. Five years later, Freud published his book The Interpretation of Dreams, which formalized much of his psychoanalytic theory.

What Happened to Anna O?

While Breuer and Freud may have painted the picture that Breuer’s treatment cured Anna O. of her symptoms, records indicated that she became progressively worse and was eventually institutionalized. 

“So the famous first case he treated together with Breuer and which was vastly praised as an outstanding therapeutic success was nothing of the sort,” Carl Jung, a former Freud disciple, noted in 1925.

In 1954, Germany issued a postal stamp bearing her image in recognition of her many accomplishments.

Researcher Mark J. Blechner suggests that Pappenheim was eventually healed thanks to three cures: the talking cure, the writing cure, and the social cure. “She was cured not just by her psychoanalytic treatment, but also by realizing her intellectual gifts via her writing and by changing the society that was making her ill,” he writes.

It is unclear whether Pappenheim felt that Breur’s treatment was helpful or successful. She left no records of her treatment by Breuer. In her own work with patients as a social worker, however, she reportedly opposed any use of psychoanalytic treatment for those under her care.

Contemporary Views

How would Anna O.’s condition be diagnosed and treated today? Hysteria is no longer seen as a valid condition. Today, people exhibiting such symptoms might be diagnosed with some type of dissociative or somatic disorder. Such disorders include dissociative identity disorder or somatic symptom disorder.

However, some experts suggest that her condition wasn’t psychological at all, and instead may have resulted from some type of physical or neurological illness. Some have suggested she may have had neurotuberculosis or some type of brain inflammation. Others have suggested that her symptoms stem from a complex partial seizure worsened by substance dependence.

The fear of death is quite common, and most people feel that dying is scary to varying degrees. To what extent this fear occurs and what it pertains to specifically varies from one person to another.

Some fear is healthy because it makes us more cautious, but people may also have an unhealthy fear of dying. Learn more about what causes a fear of dying, why people often feel that death is scary, and what you can do to manage this fear.

Who Has a Fear of Dying?

The fear of death is so common that it has spurred multiple research projects and intrigued everyone from scholars to religious leaders. There is even a field of study called thanatology which examines the human reaction to death and dying. Some interesting findings have emerged from studying the fear of death.

According to the 2017 “Survey of American Fears” conducted by Chapman University, 20.3% of Americans are “afraid” or “very afraid” of dying. It’s worth noting that this survey includes other responses that involve death which are more specific. For example, murder by a stranger (18.3%) and murder by someone you know (11.6%) are also included.

Women are more likely to have a fear of death than men. This is possibly due to the fact that women more readily admit to and discuss such fears. The fact that, historically, men are more likely to believe in dying for a cause or purpose may also contribute to this.

Some researchers argue that young people fear death more than the elderly. This is supported by studies finding greater death anxiety in people who are younger or middle-aged. However, not all studies agree. For instance, one study found that older individuals had a significantly higher death anxiety score than younger college-aged students.

Reasons Why Death Is Scary

It is possible to break down our general fear of death into several specific types of fears.

Fear of Pain and Suffering

Some people fear that when they meet death, they will experience excruciating pain and suffering. This fear can occur in healthy people, as well as in patients dying of cancer or other terminal illnesses.

Fear of the Unknown

Some people have a fear of death due to fear of the unknown, and death remains the ultimate unknown. It is human nature to want to understand and make sense of the world around us. The reality is that death can never be fully understood by anyone who is living.

Fear of Non-Existence

Some people fear that they will completely cease to exist after death occurs. We might typically associate this fear with atheists or others without personal spiritual or religious beliefs. Yet, people of faith can also worry that their belief in an afterlife isn’t real, or that they did not earn eternal life while alive.

Fear of Eternal Punishment

This is similar to the fear of non-existence in that it does not apply only to devout believers of religion or those with spiritual faith. Many people — regardless of their religious persuasion or spiritual beliefs — have a fear of death as that is when they will be punished for what they did or did not do while here on earth.

Fear of Loss of Control

Human nature generally seeks to control the situations we encounter, but death remains something over which we have absolutely no control. This lack of control frightens many people.

Fear of What Will Become of Our Loved Ones

Another common death fear focuses on the worry of what will happen to those who rely on our care if we die. Parents, for example, might worry about a newborn or child.

Individuals providing home-based caregiving to a loved one might fear that no one else can handle their patient’s many needs and demands. Someone in the prime of their life might feel afraid at the thought of leaving a spouse or partner alone due to death.

Normal vs. Unhealthy Fear of Dying

In general, the fear of death can be healthy. When we have a fear of dying, we often act more carefully and take appropriate precautions to minimize risks, such as wearing our seat belts or taking the time to put on a bike helmet.

A healthy fear of death can also remind us to make the most of our time here on Earth and to feel grateful for everything we have. Fearing the reality of death might also push us to work harder in order to leave a lasting legacy.

On the other hand, a fear of death can sometimes prove so severe that it interferes with someone’s daily life. Called thanatophobia, this intense, often irrational fear of death can consume someone’s thoughts. It may even affect the most basic decisions they make, such as refusing to leave the house just to bring in the mail.