What is the best approach to manage a patient with a psychogenic tremor of the upper arm?

Management of Psychogenic Tremor of the Upper Arm

Cognitive behavioral therapy (CBT) is the cornerstone of treatment for psychogenic tremor, with studies showing remission or near remission in up to 73.3% of patients. 1

Diagnosis Confirmation

Psychogenic tremor can be distinguished from organic tremors by several key features:

• Distractibility: Tremor decreases or disappears when attention is diverted
• Entrainability: Tremor changes frequency to match a voluntary rhythmic movement
• Variable frequency and amplitude: Inconsistent tremor characteristics
• Abrupt onset: Sudden appearance of tremor (present in 78.7% of cases) 2
• Coactivation sign: Simultaneous contraction of agonist and antagonist muscles 3
• Response to weight loading: Tremor amplitude often increases with added weight (unlike organic tremors which typically decrease) 3

Treatment Algorithm

First-Line Approach

1. Therapeutic Communication

   • Provide a clear, non-judgmental explanation of the diagnosis
   • Acknowledge that symptoms are real and not "made up"
   • Emphasize potential for improvement with appropriate treatment 1
   • Explain the neurobiological model of functional tremor

2. Cognitive Behavioral Therapy

   • Implement structured CBT focusing on:
     • Identifying and managing psychological stressors
     • Developing coping strategies
     • Addressing any underlying anxiety or depression 1

3. Physical/Occupational Therapy Techniques

   • Focus on retraining normal movement patterns
   • Superimpose alternative voluntary rhythms to disrupt tremor
   • Use gross rather than fine movements for activities like handwriting
   • Discourage tensing of muscles as a method to suppress tremor 1
   • Implement distraction techniques during functional tasks 4

Second-Line Approaches

1. Transcranial Magnetic Stimulation (TMS)

   • Can be used both diagnostically and therapeutically
   • Apply 30 TMS pulses over the hand area of the primary motor cortex contralateral to the affected hand(s)
   • Has shown to reduce tremor intensity in pilot studies 5

2. Intensive Rehabilitation Programs

   • Consider for treatment-resistant cases
   • Multidisciplinary approach including physical, occupational, and psychological therapy 1

3. Treatment of Comorbidities

   • Address underlying anxiety, depression, or other psychiatric conditions that may exacerbate symptoms 1

Important Considerations

What to Avoid

• Unnecessary aids or splinting: These may reinforce abnormal movement patterns 4, 1
• Multiple medication trials: Pharmacotherapy alone shows limited benefit 1
• Focusing solely on psychological factors: Symptoms often develop in complex contexts 1

Prognosis Factors

• Long-term outcome studies show approximately 56.6% of patients report improvement in their tremor 2
• Favorable outcome predictors include:
  • Elimination of stressors
  • Patient's perception of effective treatment by the physician 2

Follow-up Care

• Prepare patients for possible relapse
• Teach self-management techniques
• Provide clear criteria for when to seek additional treatment 1
• Regular follow-up to monitor progress and adjust treatment plan

Special Considerations

• Video recording interventions (with consent) can be useful to demonstrate changeability of symptoms and highlight successes 4
• For severe, treatment-resistant cases, consider referral to specialized functional neurological disorder clinics 1

By implementing this comprehensive approach focused on CBT, movement retraining, and appropriate psychological support, patients with psychogenic tremor can achieve significant symptom improvement and enhanced quality of life.