What is the best management approach for psychogenic tremors?

Management of Psychogenic Tremors

The best management approach for psychogenic tremors is cognitive behavioral therapy (CBT), which can significantly reduce tremor severity with remission or near remission achieved in up to 73.3% of patients. 1

Understanding Psychogenic Tremors

Psychogenic tremors (also called functional tremors) are part of functional neurological disorders (FND) and represent the most common psychogenic movement disorder. They are characterized by:

• Distractibility (tremor lessens when attention is diverted)
• Variability in amplitude and frequency
• Entrainability (can follow an external rhythm)
• Suggestibility (can worsen with suggestion)
• Abrupt onset with variable course
• Absence of other neurologic signs
• Inconsistent symptomatology
• Selective disability despite severe tremors 2, 3

Diagnostic Approach

Diagnosis should be based on positive clinical features rather than just exclusion of organic causes:

• Document distractibility by engaging the patient in conversation or cognitive tasks
• Test entrainability by asking the patient to follow rhythmic movements with unaffected limbs
• Look for coherence (whether tremor affects multiple body parts simultaneously)
• Assess for suggestibility through clinical examination
• Note any unusual temporal profiles (sudden onset, fluctuating course)
• Evaluate for selective disability (ability to perform some tasks despite severe tremor) 2

Treatment Algorithm

First-line Treatment:

1. Cognitive Behavioral Therapy (CBT)
   • Provides significant improvement in tremor severity 1
   • Associated with changes in anterior cingulate/paracingulate activity, which may represent a marker of emotional dysregulation
   • Typically delivered over 12 weeks
   • Most effective approach with documented remission rates up to 73.3%

Second-line Approaches:

1. Multidisciplinary Management
   • Speech and language therapy for communication difficulties 4
   • Occupational therapy focusing on functional movement strategies 4
   • Physiotherapy using techniques to retrain normal movement patterns

Specific Intervention Strategies for Functional Tremor:

• Superimpose alternative, voluntary rhythms to override existing tremor
• For unilateral tremor, use the unaffected limb to dictate a new rhythm
• Assist in muscle relaxation to prevent cocontraction
• Focus on gross rather than fine movements
• Discourage tensing of muscles as a method to suppress tremor 4

Patient Education

A candid but sympathetic discussion about the diagnosis is essential:

• Acknowledge the involuntary nature of the attacks
• Explain that symptoms are real and not "made up"
• Avoid language suggesting the condition is "all in your head"
• Emphasize potential for improvement with appropriate treatment 4

Avoiding Common Pitfalls

1. Avoid unnecessary aids and equipment

   • These can reinforce abnormal movement patterns
   • If aids are necessary, they should be:
     • Considered short-term solutions
     • Issued with a minimalist approach
     • Accompanied by a plan to progress toward independence 4

2. Avoid focusing solely on psychological factors

   • Symptoms often develop in the context of injury or illness
   • Absence of psychological distress should not rule out the diagnosis 4

3. Avoid multiple medication trials

   • Unlike organic tremors, psychogenic tremors typically do not respond well to medications like propranolol or primidone 5
   • Pharmacotherapy alone shows limited benefit for psychogenic tremors 4

Preparing for Setbacks

• Prepare patients for possible relapse
• Teach self-management techniques
• Provide clear criteria for when to seek additional treatment
• Make follow-up support available when needed 4

Special Considerations

For patients with severe, treatment-resistant symptoms, consider:

• More intensive psychological interventions
• Referral to specialized functional neurological disorder clinics
• Addressing comorbid conditions (anxiety, depression) that may exacerbate symptoms

By implementing this structured approach focusing on CBT as the cornerstone of treatment, clinicians can effectively manage psychogenic tremors and help patients achieve significant improvement in symptoms and quality of life.