Skip to main content Accessibility help

Demoralization in essential tremor: prevalence, clinical correlates, and dissociation from tremor severity

  • Tess E. K. Cersonsky (a1), Sarah Kellner (a1), Sarah Morgan (a1), Stephanie Cosentino (a2), Brian B. Koo (a3), John M. de Figueiredo (a4) and Elan D. Louis (a5)...



Essential tremor (ET) is associated with psychological difficulties, including anxiety and depression. Demoralization (feelings of helplessness, hopelessness, inability to cope), another manifestation of psychological distress, has yet to be investigated in ET. Our objectives are to (1) estimate the prevalence of demoralization in ET, (2) assess its clinical correlates, and (3) determine whether demoralization correlates with tremor severity.


We administered the Kissane Demoralization Scale (KDS-II) and several psychosocial evaluations (ie, scales assessing subjective incompetence, resilience, and depression [eg, Geriatric Depression Scale]) to 60 ET subjects. Tremor was assessed with a disability score and total tremor score. KDS-II >8 indicated demoralization.


Among 60 ET subjects (mean age = 70.2 ± 6.8 years), the prevalence of demoralization was 13.3%, 95% confidence interval = 6.9–24.2%. Although there was overlap between demoralization and depression (10% of the sample meeting criteria for both), 54% of depressed subjects were not demoralized, and 25% of demoralized subjects were not depressed. Demoralization correlated with psychological factors, but demoralized subjects did not have significantly higher total tremor scores, tremor disability scores, or years with tremor.


Demoralization has a prevalence of 13.3% in ET, similar to that in other chronic or terminal illnesses (eg, cancer 13–18%, Parkinson’s disease 18.1%, coronary heart disease 20%). Demoralization was not a function of increased tremor severity, suggesting that it is a separable construct, which could dictate how a patient copes with his/her disease. These data further our understanding of the psychological and psychosocial correlates of ET.


Corresponding author

*Address correspondence to: Elan D. Louis, Yale Neurology, Division of Movement Disorders, LCI 710, 15 York Street, PO Box 208018, New Haven, CT 06520-8018, USA. (Email:


Hide All

This work was supported by the National Institutes of Health (grant number NINDSR01NS086736). This funding body played no role in the design of the study, the collection, analysis, and interpretation of data, or the writing of the manuscript. None of the authors had conflicts of interest.



Hide All
1.Louis, ED, Ferreira, JJ. How common is the most common adult movement disorder? Update on the worldwide prevalence of essential tremor. Mov Disord. 2010; 25(5): 534541. doi: 10.1002/mds.22838
2.Louis, ED, Ottman, R. How many people in the USA have essential tremor? Deriving a population estimate based on epidemiological data. Tremor Other Hyperkinet Mov (N Y). 2014; 4: 259. doi: 10.7916/D8TT4P4B
3.Putzke, JD, Whaley, NR, Baba, Y, Wszolek, ZK, Uitti, RJ. Essential tremor: predictors of disease progression in a clinical cohort. J Neurol Neurosurg Psychiatry. 2006; 77(11): 12351237. doi: 10.1136/jnnp.2006.086579
4.Zesiewicz, TA, Elble, RJ, Louis, ED, et al. Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology. Neurology. 2011; 77(19): 17521755. doi: 10.1212/WNL.0b013e318236f0fd
5.Schuurman, PR, Bosch, DA, Bossuyt, PM, et al. A comparison of continuous thalamic stimulation and thalamotomy for suppression of severe tremor. N Engl J Med. 2000; 342(7): 461468. doi: 10.1056/NEJM200002173420703
6.Louis, ED. Essential tremors: a family of neurodegenerative disorders? Arch Neurol. 2009; 66(10): 12021208. doi: 10.1001/archneurol.2009.217
7.Dogu, O, Louis, ED, Sevim, S, Kaleagasi, H, Aral, M. Clinical characteristics of essential tremor in Mersin, Turkey. J Neurol. 2005; 252(5): 570574. doi: 10.1007/s00415-005-0700-8
8.Sengul, Y, Sengul, HS, Yucekaya, SK, et al. Cognitive functions, fatigue, depression, anxiety, and sleep disturbances: assessment of nonmotor features in young patients with essential tremor. Acta Neurol Belg. 2015; 115(3): 281287. doi: 10.1007/s13760-014-0396-6
9.Chandran, V, Pal, PK, Reddy, JYC, Thennarasu, K, Yadav, R, Shivashankar, N. Non-motor features in essential tremor. Acta Neurol Scand. 2012; 125(5): 332337.
10.Louis, ED. Non-motor symptoms in essential tremor: a review of the current data and state of the field. Parkinsonism Relat Disord. 2016; 22: S115S118. doi: 10.1016/j.parkreldis.2015.08.034
11.Puertas-Martín, V, Villarejo-Galende, A, Fernández-Guinea, S, Romero, JP, Louis, ED, Benito-León, J. A comparison study of cognitive and neuropsychiatric features of essential tremor and Parkinson’s disease. Tremor Other Hyperkinet Mov (N Y). 2016; 6: 431. doi: 10.7916/D86H4HRN
12.Fabbrini, G, Berardelli, I, Falla, M, et al. Psychiatric disorders in patients with essential tremor. Parkinsonism Relat Disord. 2012; 18(8): 971973. doi: 10.1016/j.parkreldis.2012.05.005
13.Louis, ED, Huey, ED, Gerbin, M, Viner, AS. Depressive traits in essential tremor: impact on disability, quality of life, and medication adherence. Eur J Neurol. 2012; 19(10): 13491354. doi: 10.1111/j.1468-1331.2012.03774.x
14.Li, Z-W, Xie, M-J, Tian, D-S, et al. Characteristics of depressive symptoms in essential tremor. J Clin Neurosci. 2011; 18(1): 5256. doi: 10.1016/j.jocn.2010.05.021
15.Huey, ED, Cosentino, S, Chapman, S, et al. Self-report depressive symptoms are dissociated from tremor severity in essential tremor. Parkinsonism Relat Disord. 2018; 50: 8793. doi: 10.1016/j.parkreldis.2018.02.031
16.Louis, ED, Benito-León, J, Bermejo-Pareja, F. Neurological Disorders in Central Spain (NEDICES) Study Group. Self-reported depression and anti-depressant medication use in essential tremor: cross-sectional and prospective analyses in a population-based study. Eur J Neurol. 2007; 14(10): 11381146. doi: 10.1111/j.1468-1331.2007.01923.x
17.Lenka, A, Benito-León, J, Louis, ED. Is there a premotor phase of essential tremor? Tremor Other Hyperkinet Mov (N Y). 2017; 7: 498. doi: 10.7916/D80S01VK
18.Smeltere, L, Kuzņecovs, V, Erts, R. Depression and social phobia in essential tremor and Parkinson’s disease. Brain Behav. 2017; 7(9): e00781. doi: 10.1002/brb3.781
19.Graff-Radford, J, Foote, KD, Mikos, AE, et al. Mood and motor effects of thalamic deep brain stimulation surgery for essential tremor. Eur J Neurol. 2010; 17(8): 10401046. doi: 10.1111/j.1468-1331.2010.02958.x
20.Louis, ED, Cosentino, S, Huey, ED. Depressive symptoms can amplify embarrassment in essential tremor. J Clin Movem Disord. 2016; 3(1): 11. doi: 10.1186/s40734-016-0039-6
21.Musacchio, T, Purrer, V, Papagianni, A, et al. Non-motor symptoms of essential tremor are independent of tremor severity and have an impact on quality of life. Tremor Other Hyperkinet Mov (N Y). 2016; 6: 361. doi: 10.7916/D8542NCH
22.Clarke, DM, Kissane, DW, Trauer, T, Smith, GC. Demoralization, anhedonia and grief in patients with severe physical illness. World Psychiatry. 2005; 4(2): 96105.
23.Clarke, DM, Mackinnon, AJ, Smith, GC, McKenzie, DP, Herrman, HE. Dimensions of psychopathology in the medically ill: a latent trait analysis. Psychosomatics. 2000; 41(5): 418425.
24.Clarke, DM, Smith, GC, Dowe, DL, McKenzie, DP. An empirically derived taxonomy of common distress syndromes in the medically ill. J Psychosom Res. 2003; 54(4): 323330.
25.Sansone, RA, Sansone, LA. Demoralization in patients with medical illness. Psychiatry (Edgmont). 2010; 7(8): 4245.
26.Frank, JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974; 131(3): 271274. doi: 10.1176/ajp.131.3.271
27.Clarke, DM, Kissane, DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002; 36(6): 733742. Figueiredo, JM. Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry. 1993; 34(5): 308311.
29.Arts-de Jong, M, DeJong, CAJ, Hermens, RP, Kissane, DW, Massuger, LM, Hoogerbrugge, N. High demoralization in a minority of oophorectomized BRCA1/2 mutation carriers influences quality of life. J Psychosom Obstet Gynaecol. 2018; 39(2): 96104.
30.Koo, BB, Chow, CA, Shah, DR, et al. Demoralization in Parkinson disease. Neurology. 2018; 90(18): e1613e1617. doi: 10.1212/wnl.0000000000005425
31.Kissane, DW, Wein, S, Love, A, Lee, XQ, Kee, PL, Clarke, DM. The Demoralization Scale: a report of its development and preliminary validation. J Palliat Care. 2004; 20(4): 269276.
32.Robinson, S, Kissane, DW, Brooker, J, et al. Refinement and revalidation of the demoralization scale: The DS-II—external validity. Cancer. 2016; 122(14): 22602267. doi: 10.1002/cncr.30012
33.Tecuta, L, Tomba, E, Grandi, S, Fava, GA. Demoralization: a systematic review on its clinical characterization. Psychol Med. 2015; 45(4): 673691. doi: 10.1017/S0033291714001597
34.Cockram, CA, Doros, G, de Figueiredo, JM. Diagnosis and measurement of subjective incompetence: the clinical hallmark of demoralization. Psychother Psychosom. 2009; 78(6): 342345. Figueiredo, JM, Frank, JD. Subjective incompetence, the clinical hallmark of demoralization. Compr Psychiatry. 1982; 23(4): 353363. doi: 10.1016/0010-440X(82)90085-2
36.Smith, BW, Dalen, J, Wiggins, K, Tooley, E, Christopher, P, Bernard, J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008; 15(3): 194200. doi: 10.1080/10705500802222972 Figueiredo, JM. Resilience and prevention of demoralization. Int J Cult Ment Health. 2015; 8(1): 7278. doi: 10.1080/17542863.2014.892522
38.Louis, ED, Barnes, LF, Wendt, KJ, et al. Validity and test-retest reliability of a disability questionnaire for essential tremor. Mov Disord. 2000; 15(3): 516523. doi: 10.1002/1531-8257(200005)15:3<516::AID-MDS1015>3.0.CO;2-J
39.Linn, BS, Linn, MW, Gurel, L. Cumulative Illness Rating Scale. J Am Geriatr Soc. 1968; 16(5): 622626. doi: 10.1111/j.1532-5415.1968.tb02103.x
40.Miller, MD, Paradis, CF, Houck, PR, et al. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res. 1992; 41(3): 237248. doi: 10.1016/0165-1781(92)90005-N
41.Louis, ED, Ottman, R, Ford, B, et al. The Washington Heights-Inwood Genetic Study of Essential Tremor: methodologic issues in essential-tremor research. Neuroepidemiology. 1997; 16(3): 124133. doi: 10.1159/000109681
42.Louis, ED, Ford, B, Bismuth, B. Reliability between two observers using a protocol for diagnosing essential tremor. Mov Disord. 1998; 13(2): 287293. doi: 10.1002/mds.870130215
43.Louis, ED, Wendt, KJ, Albert, SM, Pullman, SL, Yu, Q, Andrews, H. Validity of a performance-based test of function in essential tremor. Arch Neurol. 1999; 56(7): 841846.
44.Folstein, MF, Folstein, SE, McHugh, PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3): 189198.
45.Nasreddine, ZS, Phillips, NA, Bédirian, V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005; 53(4): 695699. doi: 10.1111/j.1532-5415.2005.53221.x
46.Yesavage, JA, Brink, TL, Rose, TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982; 17(1): 3749. doi: 10.1016/0022-3956(82)90033-4
47.Spitzer, RL, Kroenke, K, Williams, JBW, Löwe, B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006; 166(10): 10921097. doi: 10.1001/archinte.166.10.1092
48.Lawton, MP, Brody, EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3): 179186. doi: 10.1093/geront/9.3_Part_1.179
49.Morris, JC. Clinical dementia rating: a reliable and valid diagnostic and staging measure for dementia of the Alzheimer type. Int Psychogeriatr. 1997; 9(Suppl 1): 173176; discussion 177178.
50.Mehnert, A, Vehling, S, Höcker, A, Lehmann, C, Koch, U. Demoralization and depression in patients with advanced cancer: validation of the German version of the demoralization scale. J Pain Symptom Manage. 2011; 42(5): 768776. doi: 10.1016/j.jpainsymman.2011.02.013
51.Mullane, M, Dooley, B, Tiernan, E, Bates, U. Validation of the demoralization scale in an Irish advanced cancer sample. In: Breitbart, W, ed. Palliative and Supportive Care. Vol. 7. New York: Cambridge University Press; 2009: 323330. doi: 10.1017/S1478951509990253
52.Koo, B, Chow, C, Shah, D, et al. Demoralization in Parkinson disease. Neurology. 2017; 88(16 Supplement): e1613e1617.
53.Benito-León, J, Louis, ED, Mitchell, AJ, Bermejo-Pareja, F. Elderly-onset essential tremor and mild cognitive impairment: a population-based study. J Alzheimer’s Dis. 2011; 23(4): 727735.
54.Blank, K, Gruman, C, Robison, JT. Case-finding for depression in elderly people: balancing ease of administration with validity in varied treatment settings. J Gerontol A Biol Sci Med Sci. 2004; 59(4): 378384.
55.Laprise, R, Vézina, J. Diagnostic performance of the Geriatric Depression Scale and the Beck Depression Inventory with nursing home residents. Can J Aging. 1998; 17(4): 401413. doi: 10.1017/S0714980800012678
56.Lyness, JM, Noel, TK, Cox, C, King, DA, Conwell, Y, Caine, ED. Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997; 157(4): 449454. doi: 10.1001/archinte.1997.00440250107012
57.McGivney, SA, Mulvihill, M, Taylor, B. Validating the GDS depression screen in the nursing home. J Am Geriatr Soc. 1994; 42(5): 490492. doi: 10.1111/j.1532-5415.1994.tb04969.x
58.Van Marwijk, HWJ, Wallace, P, De Bock, GH, Hermans, J, Kaptein, AA, Mulder, JD. Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale. Br J Gen Pract. 1995; 45(393): 195199.
59.Robinson, S, Kissane, DW, Brooker, J, Burney, S. A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research. J Pain Symptom Manage. 2015; 49(3): 595610. doi: 10.1016/j.jpainsymman.2014.07.008
60.Vehling, S, Kissane, DW, Lo, C, et al. The association of demoralization with mental disorders and suicidal ideation in patients with cancer. Cancer. 2017; 123(17): 33943401. doi: 10.1002/cncr.30749
61.Rafanelli, C, Roncuzzi, R, Milaneschi, Y, et al. Stressful life events, depression and demoralization as risk factors for acute coronary heart disease. Psychother Psychosom. 2005; 74(3): 179184. doi: 10.1159/000084003
62.Lee, C-Y, Fang, C-K, Yang, Y-C, et al. Demoralization syndrome among cancer outpatients in Taiwan. Support Care Cancer. 2012; 20(10): 22592267. doi: 10.1007/s00520-011-1332-4
63.Mangelli, L, Fava, GA, Grandi, S, et al. Assessing demoralization and depression in the setting of medical disease. J Clin Psychiatry. 2005; 66(3): 391394. doi: 10.4088/JCP.v66n0317
64.Schmale, AH, Engel, GL. The giving up-given up complex illustrated on film. Arch Gen Psychiatry. 1967; 17(2): 135145. doi: 10.1001/archpsyc.1967.01730260007002
65.McDaniel, JS, Brown, FW, Cole, SA. Assessment of depression and grief reactions in the medically ill. In: Fogel, BS, Greenberg, DB, eds. Psychiatric Care of the Medical Patient. 2nd ed. New York: Oxford University Press; 2000: 149164.
66.Katon, WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003; 54(3): 216226.
67.Krishnan, KRR, Delong, M, Kraemer, H, et al. Comorbidity of depression with other medical diseases in the elderly. Biol Psychiatry. 2002; 52(6): 559588.
68.Sutor, B, Rummans, TA, Jowsey, SG, et al. Major depression in medically ill patients. Mayo Clin Proc. 1998; 73(4): 329337.
69.Fava, GA, Sonino, N. Depression associated with medical illness. CNS Drugs. 1996; 5(3): 175189. doi: 10.2165/00023210-199605030-00004 Figueiredo, JM. Distress, demoralization and psychopathology: diagnostic boundaries. Eur J Psychiatry. 2013; 27(1): 6173.
71.Kissane, DW, Clarke, DM, Street, AF. Demoralization syndrome—a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001; 17(1): 1221.
72.Griffith, JL, Gaby, L. Brief psychotherapy at the bedside: countering demoralization from medical illness. Focus (Madison). 2010; 8(1): 143150. doi: 10.1176/foc.8.1.foc143
73.Clarke, DM. Depression, demoralization, and psychotherapy in people who are medically ill. In: Alarcón, RD, Frank, JB, eds. The Psychotherapy of Hope: The Legacy of Persuasion and Healing. Baltimore, MD: Johns Hopkins University Press; 2012: 125157.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

CNS Spectrums
  • ISSN: 1092-8529
  • EISSN: 2165-6509
  • URL: /core/journals/cns-spectrums
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed