What is the treatment approach for tremor associated with conversion disorder?

Treatment Approach for Tremor in Conversion Disorder

The most effective treatment for functional tremor in conversion disorder combines specific movement retraining techniques with cognitive behavioral therapy, while avoiding aids that may reinforce symptoms.

Understanding Functional Tremor

Functional tremor is a common manifestation of functional neurological disorder (FND), previously known as conversion disorder. Unlike organic tremors, functional tremors have distinctive characteristics:

• Functional tremors often show variable frequency, amplitude, and direction, and may be entrainable (can be influenced by voluntary movements) 1
• Symptoms may develop in the context of injury, illness, or psychological distress, though absence of psychological factors does not rule out the diagnosis 1
• Functional tremors typically worsen with attention and improve with distraction 1

Assessment Considerations

Before initiating treatment, it's important to:

• Provide a clear, empathetic explanation of the diagnosis that acknowledges the involuntary nature of symptoms 1
• Rule out organic causes of tremor through appropriate neurological examination 1
• Assess for comorbid anxiety and depression, which are present in up to 95% of patients with conversion disorder 2
• Evaluate the impact of tremor on daily functioning and quality of life 1

Treatment Strategies for Functional Tremor

Movement Retraining Techniques

• Rhythm modification: Superimpose alternative, voluntary rhythms on top of the existing tremor and gradually slow all movement to complete rest 1
• Entrainment techniques: For unilateral tremor, use the unaffected limb to dictate a new rhythm (e.g., tapping/opening and closing the hand) to entrain the tremor to stillness 1
• Music incorporation: Introduce music to dictate a rhythm for the patient to follow, helping to override the tremor pattern 1
• Muscle relaxation: Assist the patient to relax muscles in the affected limb to prevent cocontraction 1
• Progress from rest to activity: First control tremor with the person at rest before moving on to functional activities 1
• Gross movement focus: Emphasize gross rather than fine movements (which require more concentration) 1
  • For example, in handwriting retraining, use a marker and large paper with big lettering rather than focusing on normal handwriting 1
• Discourage counterproductive strategies: Avoid cocontraction or tensing of muscles as a method to suppress tremor, as this is unlikely to be helpful long-term 1

Psychological Interventions

• Cognitive behavioral therapy (CBT): May be beneficial in patients with functional neurological symptoms, though evidence shows a non-statistically significant trend toward improvement 1
• Anxiety management techniques:
  • Diaphragmatic breathing or progressive muscular relaxation 1
  • Sensory grounding strategies (noticing environmental details, feeling textured items) 1
  • Cognitive distractors such as counting backwards and singing 1
• Slow movement activities: Encourage learning activities like yoga or tai chi to regain movement control and redirect attention away from symptoms 1

Important Considerations for Equipment and Aids

• Minimize use of adaptive equipment: Aids and equipment are generally unhelpful in the rehabilitation process for functional disorders 1
• Potential problems with aids:
  • May prevent restoration of normal movement patterns 1
  • Can cause secondary problems like joint pain and muscle deconditioning 1
  • May increase attention and focus on the affected area, potentially exacerbating symptoms 1
• If aids are necessary (e.g., for safe discharge from hospital):
  • Consider them as short-term solutions only 1
  • Use a minimalist approach 1
  • Develop a clear plan to progress from their use 1
  • Provide follow-up appointments to monitor equipment use and support plans toward independence 1

Special Considerations

• Video recording: Recording interventions (with consent) can be useful to demonstrate changeability, highlight successes, and serve as a reference for replication of strategies outside therapy 1
• Comorbid conditions: Address associated problems of pain, fatigue, anxiety, and hypersensitivity that may exacerbate tremor 1, 2
• Emotional triggers: Research suggests abnormal amygdala activity and connectivity with motor regions during emotional processing may underlie functional motor symptoms 3

Treatment Pitfalls to Avoid

• Reinforcing illness behavior: Avoid excessive focus on symptoms or providing unnecessary aids that may reinforce disability 1
• Splinting: May increase accessory muscle use, promote compensatory movements, lead to muscle deconditioning, and increase pain 1
• Dismissive approach: Failing to acknowledge the involuntary nature of symptoms can damage therapeutic alliance 1, 4
• Pharmacotherapy limitations: Unlike essential tremor, there is no evidence supporting significant benefit from pharmacotherapy for functional tremor 1, 5, 6

By implementing these specific strategies while avoiding common pitfalls, clinicians can effectively address functional tremor in conversion disorder, improving both symptom control and quality of life.