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Q: My brother, 55, has been diagnosed with benign essential tremor. Right now, he is on propanolol. If he is trying to sign his name and no one is watching, he is OK, but if someone is watching, his tremors are worse.

Are there better drugs for this? What else can he do?

-- S.M., Buffalo
A: Essential tremors can range from almost imperceptible to severe and can worsen over time. They usually involve the hands and head, sparing the legs. Speech can also be affected. It often doesn't progress to the point of physical impairment.

There are many different causes of tremors including Parkinson's disease, too many stimulants and withdrawal from drugs such as alcohol. These causes need to be excluded before a diagnosis of essential tremor should be made.

Essential tremors can begin at any age and, as you noted with your brother, are often increased by emotional stress. The cause is unknown, but the condition is sometimes inherited. Propranolol is often recommended for the management of more severe cases of essential tremor. Primidone or alprazolam may be helpful when propranolol is ineffective.

Recent research has indicated that botulinum toxin may show some promise in controlling essential hand tremor in people who fail to improve with drugs. Surgery or electronic stimulation of the brain is reserved for people who become disabled and for whom drugs aren't working.

Your brother can do much on his own. He should try not to worry and to get plenty of sleep so his tremors won't be enhanced by emotional stress and fatigue.

Also, it's been shown that ingestion of a small amount of alcohol can provide short-term relief from the tremors, so an occasional glass of wine or a cocktail may help.

Of course, support of family and friends is very important.

Question on chronic fatigue syndrome: I am tired almost all of the time regardless of how much sleep I get. I have a hard time remembering things, my back aches a lot and my eyes are always tired.

A doctor thought it might be chronic fatigue syndrome. He gave me some antibiotics and said there was nothing else that could be done. Can you help?

-- A.C., Jamestown
A: Fatigue is one of the most common symptoms reported to doctors. But chronic fatigue syndrome is something else, a recently recognized condition that is not yet well understood.

Chronic fatigue syndrome occurs mainly among adults, 20 to 40 years of age, and affects women twice as often as men.

It is not just fatigue. It is unexplained, debilitating fatigue, often with interference with the ability to concentrate, muscle pain and weakness and sometimes, low-grade fever and swollen lymph nodes.

No cause is known, but studies have shown abnormalities in the immune system that indicate a person with this syndrome may be responding to an infection or to allergies.

No exam or laboratory test in and of itself can confirm a diagnosis of chronic fatigue syndrome, but recent studies have noted neuroendocrine abnormalities in most people with the syndrome. Several recent studies found that the hormone cortisol is lower in the blood and saliva.

Often chronic fatigue syndrome is a diagnosis of exclusion. This means that a comprehensive medical history, physical exam, mental status exam, plus a battery of lab tests need to be done to rule out other disorders.

For example, one study found that more than 10 percent of people classified as having chronic fatigue syndrome by the standard criteria had a problem with depletion of phosphate, a condition that can be treated.

No medical treatment tried so far has been successful in treating the symptoms of this disorder. Some people have improved with exercise programs and behavioral therapy.

What helps most is the support and encouragement of family and friends. Above all, it's important that you know that living your life to the fullest extent possible is the best medicine and that recovery is possible in most cases.

Dr. Allen Douma welcomes questions from readers. Although he cannot respond to each one individually, he will answer those of general interest in his column. Write to Dr. Douma in care of Tribune Media Services, 435 N. Michigan Ave., Suite 1400, Chicago, Ill. 60611. His e-mail address is

This column is for informational and educational purposes only. It is not intended to provide medical advice or take the place of consultation with a doctor or other health care provider.

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