Shaking hands and voice

What is happening in your body

When you feel under threat, your body releases adrenaline. Your heart beats faster, your muscles tense and get ready to move, and your breathing changes. Small muscles, such as those in your hands and voice box, can tremble. Your voice may shake, crack or sound thin. Your mouth may go dry.

This is normal. Everyone’s hands shake when they are frightened enough. In social anxiety, the problem is that the shaking becomes a fear in itself: “They’ll see my hand shake and know I’m nervous.” Trembling is one of the most talked-about symptoms: an analysis of posts on Reddit’s social anxiety forum found it was the physical symptom people mentioned most.

Common moments include holding a cup or glass, signing your name while someone watches, using a card machine, raising your hand, and the first sentences of a talk.

Do other people notice?

Much less than you think. The shaking you feel from inside is usually far bigger than what anyone sees or hears. In a set of experiments, people believed their inner feelings showed far more than they did. Researchers call this the illusion of transparency.

A small tremor in your voice often sounds like nothing to listeners, or like normal emotion. If someone does notice, most people feel sympathy. Many have felt the same.

What makes it worse

• Gripping. Holding a cup, pen or notes very tightly tenses the muscles and can make the shaking more visible.
• Hiding. Keeping your hands in your pockets, never holding a drink, only half-filling cups, or holding things with both hands.
• Fighting it. Trying to force your hand or voice to be still focuses your attention on it.
• Avoiding. Not speaking, not eating in front of people, not signing things in public.
• Too much caffeine before a stressful event can add to shaking.

These safety behaviours feel protective. They keep the fear going, because you never learn that people do not notice or care. In an experiment, safety behaviours and watching yourself turned out to be unhelpful in several ways. In a small study of eight people, facing situations without the safety behaviours lowered anxiety more than facing them with safety behaviours still in place.

What keeps social anxiety going explains the loop.

What helps

Treating the fear. The best-tested option is cognitive therapy for social anxiety. It includes testing what happens when you let your hands shake, and watching video of yourself to see how little shows. Exposure on your own works on the same idea.

Letting it happen. Loosen your grip. Let your hands rest or move naturally. Keep talking if your voice wobbles. Shaking that you stop fighting often settles on its own.

Slow breathing. Many people find a slow out-breath helps calm the body, for example breathing in for 3 and out for 6. It is a way to cope in the moment, not a treatment for social anxiety itself.

Propranolol. This is a beta-blocker: a heart medicine that blocks some effects of adrenaline. It is the medicine people ask about most for shaking.

• What people report. On Reddit, people often say it calms the shaking and racing heart but “not the thoughts”. The fear of being judged is still there. Some report tiredness or nausea. People also get different advice on whether to take it only before events or every day.
• What trials show. A review of the trials found only one trial in social phobia, with 16 people, and judged the evidence not enough to support routine use. Canadian guidelines do not recommend propranolol for the general form of social anxiety disorder.
• Safety. It is not safe for everyone. The NHS lists people with asthma, low blood pressure, a slow heart rate or diabetes among those who need to check with a doctor first. A doctor must prescribe it. Never borrow someone else’s.

See propranolol for more. Medicines that treat social anxiety itself, such as SSRIs and SNRIs, work more slowly and need a doctor too.

When to see a doctor

See a doctor if your hands shake when you are calm and alone, if the shaking is getting worse over time, or if it comes with other symptoms such as weight loss or a fast heartbeat at rest. Shaking can have other causes, such as some medicines or an overactive thyroid. See a doctor too if fear of shaking makes you avoid work, study or seeing people.