Essential tremor (ET) is an extremely common and widespread disorder.1 Its prevalence among individuals Ն65 years of age 2 is similar to that of osteoarthritis, 3 diabetes mellitus, 4 and Alzheimer's disease. 5 Also, it is a longstanding condition; humans have provided written commentary about their tremors for several thousand years. [6][7][8][9] Despite this, knowledge about the biology of this disorder remains limited. For example, the location of the primary pathology in ET is not known. It is not clear whether the problem originates in a central pacemaker in the brainstem and then secondarily involves the cerebellum, or whether the cerebellum or other central structure is the site of the primary pathology. 10 One problem is that a specific degenerative neuronal population has not been identified. In terms of etiology, while most investigators would agree that a genetic predisposition contributes to the etiology in a sizeable proportion of ET cases,11,12 whether this represents 10%, 50%, or 90% of cases is not known.
13Nature vs. Nurture How much do genetic vs. non-genetic factors contribute to the etiology of ET? There are published examples of families in which multiple relatives have ET [14][15][16][17] and in which the pattern of inheritance is most consistent with an autosomal dominant model. In a small number of these, [15][16][17] linkage has been demonstrated to regions on chromosomes 2p or 3q. It is commonly stated in the literature that 50% of ET cases occur on a genetic basis, although the studies examining this issue have methodological flaws, and some estimates are as low as 17%.
13Most important is that these studies have not enrolled control subjects, so it is not known to what extent familial occurrence of ET is explained by chance co-occurrence of a highly prevalent disorder rather than a genetic predisposition for tremor.
13ET is not completely genetic. The entity of nonfamilial ET or "sporadic" ET is well recognized by most clinicians, who distinguish this form of ET from "hereditary" ET. 11,16,18 In fact, in most series, the majority (>50%) of ET cases have not reported affected relatives, 3,[19][20][21][22] and despite the high prevalence of the disease, families that are informative for genetic linkage studies have been difficult to locate. The existence of intrafamilial differences in age of onset and severity of tremor 23,24 also suggests that environmental (or perhaps other genetic) factors may serve as modifiers of an underlying susceptibility genotype.The existence of geographic clusters of ET cases could provide further support for the notion that environmental factors contribute to the etiology of ET in these geographic regions. A large cluster of ET cases has been reported 20,25 to occur in a region of the Eastern Highlands of Papua New Guinea. In the population defined by possession of one or other of the following languages, Kamano, Ayuna, Gadsup, Tairo, or Agarabe, the prevalance of ET is 22.6 times higher than that of other areas of the Highlands (e.g., Fore, Keiagana-Kanite...