What causes fatigue and tremors in wrists?

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Posted on Mon, 8 Sep 2014 in Mental Health
Question: Dear Doctor,
I’m a European 22 year old male.
for the past year I've been suffering from seemingly unexplainable symptoms, which have been getting progressively worse. I've been through a series of medical examinations which didn't find anything. My doctors are clueless and I am desperate. I hope you may have some suggestions. I would be very much in your debt if you do.

symptoms:
1) persistent unbearable fatigue: worst in the morning and afternoon, worse after eating a meal and standing up and drinking coffee. Better after lying down with legs up and after drinking alcohol. Better at 9pm. Otherwise the fatigue prevents me from doing most normal daily things. I can barely sit and watch videos, eat and use the toilet. I can't do any work whatsoever. When sitting I fall asleep during the day.
2) resting and intention tremor (when rotating wrists)
3) sluggish memory, occasional memory lapses (forgetting my friends' names, forgetting words).
4) clumsiness - when pressing buttons on computer or microwave I often miss the button; when opening drawers or doors I grasp air instead of the handle, etc.
5) eye coordination problems - when reading my eyes jump over words causing me to misread words for something else or just omit words.
7) cognitive difficulty - with mental arithmetics, planning; often mispronouncing words or using different words than appropriate in the sentence, speech difficulty
8) 'temporal seizures/ derealisation episodes' (not proven but suggested by my neurologist)
9) stiff rigid muscles all around the body, especially in my hands, the neck and Temporomandibular joint area. (I've had orthodontic braces for the past 2.5 years correcting underbite)
10) pain and pressure behind the eyes, urge to blink often, spastic blinking

Diagnosis:
1) MRI scan of the brain (no contrast and limited scan of frontal lobe due to braces): clean
2) EEG of the brain: clean
3) blood tests: ALL WITHIN RANGE
- includes: thyroid function, liver function, vitamin B12, kidney function, serum electrolytes, full blood count, glucose, gluten intolerance, Lyme disease, ACE level, folate, C3/C4, ESR, CRP
4) urine microscopy: clean
5) sleep study: clean (stable amount of oxygen in blood -> no sleep apnea)
6) neurological examination: clean
     - no papilledema, no nystagmus, negative Romberg, plantar response - flexion, symmetrical reflexes,      normal visual acuity, normal lower cranial exam, no sign of limb weakness
7) blood pressure monitoring: normal
8) psychiatrist: memory problems, otherwise little evidence for mental illness
9) complete internal examination of all organs with ultrasound: clean
10) EKG: clean
- no family history of any disease, no childhood history, no epilepsy, no drugs ever taken (legal or illegal)

Questions:
1) Could all of this be caused by anxiety disorder/ depression?
2) What all tests would you recommend to rule out all possible non-psychiatric conditions? I’m thinking of PET and some more blood tests? Repeating MRI without braces? I want to be absolutely certain that I can’t have anything, as rare as it might be, before I can proceed with psychological treatment.
3) What's the most probable condition I'm suffering from?
 
doctor
Answered by Dr. Dariush Saghafi 4 hours later
Brief Answer:
Likely NON-NEUROLOGICAL

Detailed Answer:
Good afternoon sir. My name is Dr. Dariush Saghafi. I am a neurologist in both academic and private practices in XXXXXXX OH. I have read with interest your list of symptoms and test results and am sorry you have run into this road block of sorts at such a young age. Hopefully, I can give you some ideas as to what course would be a fruitful one to follow.

First of all let me reassure you that rarely are doctors in this day and age "clueless" and rarely SHOULD patients feel "desperate" in such circumstances. The art in discovering the "clues" and arriving at either a diagnosis or strategy comes from organizing the information so that it can be easily analyzed and matching that against what is known to come up with what is most probable. The body is an amazing piece of machinery. In my opinion, it rarely lets you down, and when it's not working well....it always tells you what's wrong....problem is most people DON'T KNOW HOW TO LISTEN TO IT when it talks.

So let's go back for a moment and listen again to what your body has been saying. First of all, can you tell me when the last time was that you felt PERFECTLY 100% like a million bucks? In other take me back to a time before all of this started happening. When was that...how long ago? Then, let's come up in time slowly. Did all these systems come on at once? Did they all come on like gangbusters or was it a slow, steady progression that just got a little worse and a little worse, etc.? Can you order the symptoms for me chronically? Which came first, second, etc?

Now, lay out (over the same period of time) any and all NON-PHYSICAL stresses, events, or "troubles" that have befallen you in the 6 months preceding the first physical symptoms and your list of problems above. And let's run that all the way through the present. Write that out please so that you can refer to things or even upload it so we can see it.

I am now going to take the list of symptoms and problems you've mentioned and simply repeat it down below and then, address things while putting them into context along with the diagnostic tests that have been done and see if we can make sense out of anything. Look for MY comments below each of your points if I feel there is something there that I'd like to comment on or draw to your attention.

Sound good? Here we go:

1) persistent unbearable fatigue: worst in the morning and afternoon, worse after eating a meal and standing up and drinking coffee. Better after lying down with legs up and after drinking alcohol. Better at 9pm. Otherwise the fatigue prevents me from doing most normal daily things. I can barely sit and watch videos, eat and use the toilet. I can't do any work whatsoever. When sitting I fall asleep during the day.

>>>>Persistent and unbearable Fatigue as a presenting neurological symptom most often is related to some form of sleep disorder, neuromuscular disease such as myathenia gravis, endocrinological dysfunction (such as thyroid, adrenal, or pituitary gland malfunction), metabolic derangements such as electrolyte imbalances, severe malnutrition or dehydration, or some form of demyelinating disease such as very commonly MS or SARCOIDOSIS.

However, by way of testing we are told that MRI, EEG, blood work, and EKG are perfectly fine. It would be extremely difficult for blood work to be dead normal if there were fulminant glandular or other metabolic problems causing this degree of fatigue and distress. Furthermore, the fatigue and lethargy that causes people to be physically unable to carry on as seen in MS or Myasthenia Gravis is one that generally gets worse as the day goes on. In the case of MG it's actually fluctuating which means that it gets better then worse then, better then, worse, and cycles like that throughout the day. This fatigue you have is actually from the time you get up and if anything may get better as the day goes forward....kind of reverse of what we'd expect for some type of metabolic or other physical disorder.

There are a couple of sleep disorders that might fit this XXXXXXX of extreme fatigue and tiredness that simply makes one ridiculously dysfunctional. One is Sleep Apnea and the other is Narcolepsy.

However, again a sleep study is perfectly normal....likely would show some abnormality with such fulminant symptoms.



2) resting and intention tremor (when rotating wrists)

>>>>>> I cannot really find anything here to talk about since I'd actually need to see it to understand what you're referring to. I must take the neurologist in this case at his word when he says you've got a neurological examination and trust that if there were any tremors of clinical significance that he would've detected them and reported a diagnosis such as either Parkinson's disease, Essential Tremor or something else. Fair enough? So let's leave this alone for the time being.

3) sluggish memory, occasional memory lapses (forgetting my friends' names, forgetting words).

>>>>>>Again, I must appeal to the normal neurological and psychiatric examinations which we must have faith would've picked up on some organic form of disease here such as a behavioral disturbance affecting memory, dementia, cortical atrophy (not seen in the MRI), etc.

4) clumsiness - when pressing buttons on computer or microwave I often miss the button; when opening drawers or doors I grasp air instead of the handle, etc.

>>>>>Not sure exactly how to interpret this because again the neurological exam did not reveal any cerebellar problems which could explain why you would hit wrong buttons, if there were processing problems of visual information that would've also showed up either in the MRI scan, blood work, or on the examination and it didn't. Perhaps this ties in more to the fatigue factor, don't you think that's a good place to put that set of circumstances?

5) eye coordination problems - when reading my eyes jump over words causing me to misread words for something else or just omit words.

>>>>>Now you didn't say you'd had an opthalmological examination but again when talking about words DISAPPEARING or ignoring things that could be better interpreted as either some form of neurological issue with brain processing.....and again normal neurological examination.

7) cognitive difficulty - with mental arithmetics, planning; often mispronouncing words or using different words than appropriate in the sentence, speech difficulty

>>>>>>Again, language dysfunction and mental incapacity related to any organic form of disease such as dementia, pseudodementia, Wernicke's syndrome, etc. would've been easily detected by the neurologist and likely would've had some MRI findings to go with it......

8) 'temporal seizures/ derealisation episodes' (not proven but suggested by my neurologist)

>>>>>>Highly unlikely since you haven't really said anything about convulsing, zoning out with loss of chunks of time that you can't recall at all.....with temporal seizures it is often the case that others will notice a change in behavior during seizures even if it's not frankly convulsive.....PLUS NORMAL EEG? Again, see first 2 words above.

9) stiff rigid muscles all around the body, especially in my hands, the neck and Temporomandibular joint area. (I've had orthodontic braces for the past 2.5 years correcting underbite)

>>>>>>If they are not spastic (and that would've been detected by the neurologist on a cranial nerve as well as general muscle exam) and they're just stiff feeling cramped (i.e. no actual Charley Horses present) then, you are telling me one of the most common physical manifestations of mental stress and tension.

10) pain and pressure behind the eyes, urge to blink often, spastic blinking

>>>>>Now, THIS symptom INTERESTS ME---- You've saved the best for last. You couldn't've done this on purpose now, could you? It's like writing a good book and then, waiting till the very end to reveal WHO DUNNIT! LOL!

The symptoms of pain and pressure behind the eyes is very reminiscent of my patients who are having either prodromes to headaches disorder (such as migraines and such) or these simply may be prodromes to migraines without the headaches themselves. And when you throw the blinking and perhaps spastic blinking that could take us to an entity known as a acephalgic form of migraine with a tic disorder.....or headache syndrome (without much of the headache) and nervousness/anxiety (you say SPASTIC BLINKING)


Again, please recall after the aforementioned discussion of your symptoms that:

ALL DIAGNOSTIC TESTS, LABS, AND MEDICAL EXAMINATIONS BY SPECIALISTS HAVE REVEALED NORMAL AND NONFOCAL FINDINGS. PSYCHIATRIC EXAMINATION HAS ITSELF BEEN UNIMPRESSIVE AND ACTUALLY STATED TO BE NORMAL.

Therefore, and in specific answer to your questions I would say the following:

1) Could all of this be caused by anxiety disorder/ depression?

>>>>> YES, these symptoms and malfunctions can all be a reflection of anxiety/depression or similar psychological issues. I know the psychiatrist said you didn't exhibit any problems, HOWEVER, in the USA when one goes to see a psychiatrist....it's likely no more than 10-15 minutes and on your way with a prescription whether you need it or not...whether you believe or not....sad to say like it is...but there are very very few practicing psychiatrists who will take any time at all to go through detailed testing batteries, or take time to really delve into people's pasts and lives to figure out where all the stress triggers and points of possible friction are that could lead them to become UNKNOWINGLY stressed out and thus develop a lot of somatic symptoms that drive them looking for answers in a lot of expensive tests and making all these specialists scratch their heads. What I believe you need to do is to seek out a GOOD PSYCHOLOGIST who is willing to be deliberate and patient with your case. I suspect there are things that you can talk about to help shed some light on what's going on.


2) What all tests would you recommend to rule out all possible non-psychiatric conditions? I’m thinking of PET and some more blood tests? Repeating MRI without braces? I want to be absolutely certain that I can’t have anything, as rare as it might be, before I can proceed with psychological treatment.

>>>> With the data that is present and the Bull's eye symptom I believe with #10 combined with #1 (intense fatigue without obvious physiological correlate) I really and truly would not look to spend either your money or anybody else's trying to go for more sophisticated tests because it's extremely unnecessary at this point. Absolutely, NO PET scan. There is absolutely no cause to get such testing done to look at metabolic expenditures of the brain. I will tell you with 99% confidence it will be normal in your case and will not show temporal seizures, tumors, or dementias. I would not spend any time or money on more bloodwork. No more tests at this point.

What I might suggest you do is get yourself a good little HEADACHE DIARY.....download one from about a million different internet sites and start keeping track of the pain behind your eyes....duration, quality of pain, intensity of pain, other symptoms associated such as nausea/vomiting, flashing lights, sensitivity to light, sound, smells, ringing in the ears, changes in vision such as blurriness, haziness, "heat waves coming up from the pavement"...etc. And keep track of these things as they relate to your other symptoms....does the eye pain come on when you are REALLY FATIGUED, otherwise, nervous, clenching your jaw, etc. etc. etc. How much sleep do you get at night, nightmares? How much caffeine do you ingest, alcohol, other illicit substances, etc.

I would seriously ask you (if you were my patient) to keep such a log for a good 30-45 days as well as keeping track of what you do to take care of the symptoms when present (i.e. take medications, cold wash rag, go into a dark room, etc.?). Then, if the neurologist is a GOOD one he will know what to do with the log....if not, find a headache specialist. If this turns out to be something like a migraine tic-disorder or acephalgic migrainous tic on a background of depression or anxiety then, the treatment would be the underlying psychological issues with or without specific headache remedies depending on what types of headaches most likely are associated (if there are even any headache; it could be just the prodrome without the actual headache).

3) What's the most probable condition I'm suffering from?

>>>>>I just outlined it for you in everything else. I believe there is a strong possibility that just based on everything you've presented here today that there is a headache syndrome afoot which is likely SECONDARY or consequent to a psychological entity of either stress/anxiety/depression or a slight combination of all those.

I wish you all the best and if there are more questions please do tell.

Otherwise, if these writings have provided you with any measure of useful information or maybe even relief to know you're not going bonkers and that there's still plenty of hope for you to win the Nobel Prize if you'd like then, would you do the favor of a little written feedback with STAR RATING? We get lollipops based on the number stars people stick on our foreheads! HA!

Also, if you've no other questions to forward for now please do CLOSE THE QUERY on your end to that the network will know that I satisfactorily met your needs. I thought I'd let you know that you could also find me on live webcam duty on a network known as HealthTap. You can log in to that site at www.healthtap.com. I am on duty in the state of OHIO on Wed-Sat evenings 3a-7a Eastern Standard Time (New York City Time Zone). If you have a webcam hooked up to your computer we can actually conference live in real time and you can also upload your labs and other results that I can reference and look at if you wanted to consider that as an alternative form of communication. You would want to look me up as Dr. Dariush Saghafi.

Also, you specifically direct further questions to MY attention on this network and I would be the one to receive the questions if interested.

This query required 156 minutes of physician specific time for review, research, and consolidation for final draft envoy.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 2 days later
Thank you so much for a such a detailed answer! I'll do as you suggested and if I have any more queries i'll get in touch on health tap.

All the best!
doctor
Answered by Dr. Dariush Saghafi 21 minutes later
Brief Answer:
Please rate our discussion and close query

Detailed Answer:
I'm very happy that you found the information useful though it was a bit detailed. But that is to be sure you have all your questions answered and the means to proceed with your own doctors more reliably.

If you are of the opinion that we have provided a useful service and answered your questions would you do me the awesome favor a written note of feedback as well as STAR RATING. Also, if there are no further questions at this time your CLOSING THE QUERY is very much appreciated so that the network can see that I have answered the consult satisfactorily and will then, archive it for future reference.

Cheers!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2436 Questions

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