Essential Tremor Patients Retain Empathy Despite Cognitive Decline

Social Cognition and the Non-Motor Dimensions of Essential Tremor

Essential tremor is increasingly recognized as a complex multisystem disorder rather than an isolated motor condition, with research now focusing on its diverse non-motor phenotype [1]. While the hallmark of the disease is kinetic tremor, clinicians often observe comorbid cognitive impairment and social challenges that significantly impact patient quality of life [2]. These social difficulties may stem from dysfunction in the cerebellum and basal ganglia, regions traditionally associated with motor control that also play vital roles in the neuroanatomical networks governing social perception and theory of mind (the cognitive ability to infer the mental states of others) [3]. Understanding these socio-cognitive domains is critical because impairments in social interaction can lead to profound social isolation and psychological distress for both patients and their caregivers [4, 5]. A recent cross-sectional study of 40 patients found that while essential tremor patients had significantly lower Montreal Cognitive Assessment scores than healthy controls (22.1 vs. 25.3, p < 0.001), their self-reported empathy and alexithymia (a clinical inability to identify and describe one's own emotions) remained largely preserved at the group level [1].

Comparative Assessment of Cognitive and Emotional Function

To investigate the intersection of motor symptoms and social cognition, researchers utilized a cross-sectional design to evaluate empathy and alexithymia in patients with essential tremor compared with healthy controls. The study cohort consisted of 40 patients diagnosed with essential tremor and 40 healthy controls, providing a direct comparison of socio-emotional profiles between the two groups. The researchers aimed to explore potential associations between empathy, alexithymia, and global cognition to determine if the cognitive decline often seen in this population extends to emotional processing and social resonance. Participants underwent a comprehensive battery of assessments to quantify these domains. Global cognitive function was measured using the Italian version of the Montreal Cognitive Assessment (MoCA), a screening tool used to detect cognitive impairment across domains such as executive function and visuospatial skills. Social resonance and the ability to understand the perspectives of others were evaluated using the short Empathy Quotient (EQ-short). Additionally, the researchers utilized the Toronto Alexithymia Scale (TAS-20) to measure the degree to which participants could identify and communicate their internal emotional states. These instruments allowed for a nuanced look at whether the neurodegenerative processes in essential tremor disrupt the affective components of social interaction. The results revealed a clear divergence between cognitive performance and emotional preservation. Patients with essential tremor had significantly lower MoCA scores than healthy controls (22.1 ± 4.1 vs. 25.3 ± 3.2, p < 0.001), confirming a baseline of global cognitive deficit in the patient group. Despite this measurable decline in cognition, the study found that scores on the EQ-short and TAS-20 did not differ significantly between the two groups. These findings suggest that while patients may struggle with executive or memory tasks, their fundamental capacity for empathy and their ability to process their own emotions remain intact at the group level.

Preservation of Empathy and Emotional Awareness

The clinical understanding of essential tremor has expanded to include selective alterations in some socio-cognitive domains (the mental processes involved in perceiving and interpreting the intentions and emotions of others). However, previous findings regarding self-reported empathy and alexithymia (a clinical difficulty in identifying and describing one's own emotional states) have remained limited and inconsistent. This study clarifies these non-motor dimensions by demonstrating that despite measurable cognitive decline, the affective components of social interaction remain stable. Specifically, the researchers found that no significant between-group differences were found for EQ-short scores, which quantify empathy, nor were there significant between-group differences for TAS-20 scores, which assess alexithymia. These results provide important diagnostic clarity for clinicians managing the long-term care of patients with essential tremor. The findings do not support a group-level deficit in self-reported empathy or alexithymia in essential tremor, indicating that socio-emotional functioning may be largely preserved at the group level even as motor symptoms and global cognition fluctuate. While the researchers noted that the relationship between social skills and emotional self-description may differ in patients compared to healthy controls, the fundamental capacity for emotional resonance appears resilient. For the practicing physician, this suggests that the neurodegenerative process in essential tremor does not uniformly erode the patient's ability to maintain social connections or process internal emotional experiences, allowing for a more optimistic prognosis regarding the preservation of the patient's social identity.

Divergent Correlations in Social-Emotional Processing

Social cognition, which encompasses the mental processes required to perceive and interpret the intentions and emotions of others, is increasingly recognized as part of the non-motor phenotype of essential tremor. In this study, researchers observed a distinct decoupling of cognitive and emotional metrics in the patient group that was not present in the healthy cohort. Specifically, in patients with essential tremor, Montreal Cognitive Assessment (MoCA) scores were not significantly associated with empathy or alexithymia measures. This lack of correlation suggests that the decline in global cognition often observed in these patients does not necessarily predict a corresponding loss of emotional awareness or empathic capacity. In contrast, the control group exhibited a more traditional cognitive-emotional link; in healthy controls, higher MoCA scores were associated with greater emotional reactivity, indicating that in the absence of pathology, cognitive efficiency may support more robust emotional responses. Further investigation into the internal structure of these emotional traits revealed unique patterns within the patient cohort. Exploratory bivariate analyses (statistical tests looking at the relationship between two variables) suggested inverse associations between social skills and alexithymia in essential tremor. This implies that as social competence increases, the clinical difficulty in identifying and describing emotions tends to decrease. However, the researchers noted that only the adjusted models for essential tremor remained significant regarding the association between social skills and alexithymia, suggesting that the relationship is robust only when accounting for specific confounding variables. These findings highlight that the relationship between social skills and emotional self-description may differ in essential tremor compared to healthy controls. For the practicing clinician, this distinction is vital for patient management and family counseling. While patients may struggle with global cognitive tasks, their ability to navigate social environments and process emotions follows a different trajectory than that of healthy individuals. Understanding that social skills and emotional self-awareness are linked differently in this population can help physicians tailor their communication strategies, ensuring they do not assume a patient's social or emotional competence based solely on their cognitive screening results.

References

1. Maggio MG, Luca A, Cicero C, et al. Empathy and alexithymia in essential tremor. Frontiers in Psychiatry. 2026. doi:10.3389/fpsyt.2026.1794068

2. Rizzo G, Martino D, Avanzino L, Avenanti A, Vicario CM. Social cognition in hyperkinetic movement disorders: a systematic review.. Social neuroscience. 2023. doi:10.1080/17470919.2023.2248687

3. Bodden M, Dodel R, Kalbe E. Theory of mind in Parkinson's disease and related basal ganglia disorders: A systematic review. Movement Disorders. 2009. doi:10.1002/mds.22818

4. Crooks S, Mitchell G, Wynne L, Carter G. Exploring the stigma experienced by people affected by Parkinson’s disease: a systematic review. BMC Public Health. 2025. doi:10.1186/s12889-024-21236-8

5. Hienen MMV, Contarino MF, Middelkoop HAM, Hilten JJV, Geraedts VJ. Effect of deep brain stimulation on caregivers of patients with Parkinson's disease: A systematic review. Parkinsonism & Related Disorders. 2020. doi:10.1016/j.parkreldis.2020.09.038