Sauerhoefer et al. Journal of Medical Case Reports 2011, 5:158 http://www.jmedicalcasereports.com/content/5/1/158 reduced in degree (reduction of 80%). Despite the pre- sence of a slight tremor, the girl was able to write with the aid of the customized wrist brace (Additional file 3). After completion of the therapy, our patient described what had helped her most in dealing with the symptoms of her tremor. First was to become more physically active rather than retiring alone to her room to listen to music. In doing so, she was able to cope with her symp- toms both on a physical and on a social (interpersonal) level as she had been taught in therapy. Secondly, iden- tifying and relating her feelings to others. Thirdly, learn- ing and practicing a relaxation method to reduce her stress, in this case PMR, which had initially proven diffi- cult for her, but which she was able to master in the end. Finally, attending regular physical therapy sessions helped in ameliorating her symptoms. Outcome and follow-up Our patient had her first check-up two weeks after being discharged from our clinic, after a total duration of in-patient hospitalization of three months. At this time the tremor had ceased altogether and reappeared only about once every two months in extremely stressful situations. She reported that her parents were still living together, but planned to split up. The total duration of her treatment was nine months (Additional file 4). Discussion No definite recommendations for treatment of pro- nounced psychogenic tremor in adolescents were found in the literature on this topic. Due to the complex nat- ure of this disorder, the difficulty of diagnosis and the often prevailing convictions of the patient that the cause of their suffering is physical in nature, this disorder often goes unrecognized and is not properly treated. To lend further credence to the diagnosis of psycho- genic tremor, typical signs of the disorder could be observed in our patient. For the most part the symp- toms of dissociative (conversion) disorder begin abruptly and without being related to a specific event, as hap- pened in our case. When treating these disorders, it is of utmost impor- tance to intervene quickly as this has considerable impli- cations for the prognosis. The prognosis was found to be dependent on the amount of time which elapses between the time symptoms become evident and ade- quate treatment begins. The shorter this time period was, the better the prognosis. Another factor was the success of the treatment during the in-patient treatment. In patients whose symptoms decreased during the initial phase of the hospital stay, 96% of them saw definite positive outcomes, whereas in patients that had no initial decrease of symptoms, only 30% later had positive outcomes [4]. Page 3 of 4 In our case, our patient was admitted only several days after the onset of symptoms. After a thorough phy- sical exam revealed no neurological etiology, our patient was admitted to our department for treatment with a case of suspected psychogenic tremor. Treatment of dissociative disorder should include the non-judgmental acceptance of the presenting symptoms, or rather the avoidance of accusing the patient of simu- lation, and respect for the somatic problems of the patient. In our case, after the physiotherapist suggested the girl was pretending to have the tremor, the tremor was aggravated. Afterwards the girl told us that she was really disappointed and angry because the physiothera- pist did not accept her symptoms. The use of symptom-oriented approaches, both directly and indirectly, seem to be of particular benefit in the treatment of dissociative disorder. Direct therapy would include physical therapy exercises, for example, gradually increasing strain on the body part in question through the use of crutches, physiotherapy and manual therapies with the goal of symptom reduction under the self-control of the patient, which enables them to save face and “escape with honor” [5]. The success of cognitive-behavioral therapy requires the motivation and the co-operation of the patient. Posi- tive feedback through the use of video recordings or clear signs of improvement, which increase the patient’s motivation, can be integrated into cognitive behavioral therapy [4]. Video recordings were also used extensively in the girl´s case, to show her the reduction of her symptoms during the course of her hospitalization. The goal of cognitive-behavioral approaches is to obtain an understanding of the psychological causes of the disorder, in this case conflicted relations in the family, feeling overwhelmed at work or at school due to exam anxiety, to reduce avoidance behavior, which is seen as unwanted behavior, and to positively reinforce desired behavior. With the aid of a customized wrist brace, the girl was able to return to school and write despite the presence of a marked tremor, which in turn reduced her avoid- ance behavior and hence noticeably reduce her exam anxiety. Conclusion After comprehensive clinical diagnostics, our patient’s psychogenic tremor was treated with cognitive-beha- vioral therapy, which offers a pragmatic approach to reduce symptoms. This treatment should be adapted to the needs of the patient and typical mistakes like accus- ing the patient of simulation should be avoided. With the aid of a customized wrist brace, the girl was able to attend school and to write despite the presence of a