Sauerhoefer et al. Journal of Medical Case Reports 2011, 5:158 http://www.jmedicalcasereports.com/content/5/1/158 physiotherapist asked her to “stop pretending”, a notion that caused prolonged anger and sadness in her. Our patient agreed to be transferred to the child and adolescent psychiatric department. The tremor contin- ued after admission and it could only be interrupted by either grasping an object in her hand or clenching her hand. She was not able at this time to either write or perform activities requiring fine motor skills (for exam- ple, cutting something with a knife). In order to fall asleep our patient had to either lie on her hands or hold an object in her hands. Personal and family history Our patient was attending the 7th grade in an academic secondary school and was in danger of failing academi- cally. There was no history of psychiatric, neurologic or other severe somatic disorder in her past. She lived with her parents, who had been fighting regularly for years. The question of a separation was an issue between them, but they reported never having talked about it openly with their daughter. Investigations Our patient was appropriately developed for her age. Her cardio-pulmonary status and the results of examina- tions of her head, neck, abdomen, skin and genitals were all normal. The finger to nose test, motor proficiency tests, pupil- lary reactions and eye movement tests were all normal. Her reflex status showed normal tonicity for both sides of her body, no meningism was present, gross strength was normal and sensitivity was normal for both sides of her body. During the examination the tremor ceased. At rest a low frequency hand tremor could be observed (approximately 5/s) in both hands. By the end of the physical examination the tremor changed from a low frequency tremor to a diadochokinetic tremor (Addi- tional file 1). Blood tests revealed no abnormalities, including thyr- oid stimulating hormone. Ceruloplasmin, serum copper and urine copper levels were taken and an ophthalmolo- gical evaluation was performed to rule out Wilson’s dis- ease. The results of cranial magnetic resonance imaging and an electroencephalogram were normal, as were results of a cerebrospinal fluid abdominal ultrasound. Psychiatric diagnostic testing included German ver- sions of the Anxiety Questionnaire for Children, which showed a high tendency toward social desirability and performance anxiety (schoolwork). Our patient showed above average intelligence (HAWIK-IV, German version of WISC: IQ = 124). A scale to measure depression in children showed no marked symptoms of depression. For observation purposes and for a more precise diagno- sis, the patient was filmed. Page 2 of 4 Our patient’s symptoms were noticeably lessened when her attention was on something else, for example on mental arithmetic. Concentrated on her tremor resulted in it becoming intensified. During her examina- tion, the tremor fluctuated greatly. An entrainment test [3] showed that when our patient tapped a rhythm with her contra-lateral hand, the tremor matched this new rhythm and at times ceased altogether. Treatment Our patient completed a comprehensive medical-beha- vioral therapy which included individual and group ther- apy sessions (client-centered in orientation) and anxiety- reducing techniques, especially in the area of perfor- mance anxiety. She also learned progressive muscle relaxation techniques (PMR). One important aspect of the treatment was to work with our patient to help her understand what triggered her tremors and kept them from diminishing. In parti- cular, her performance anxiety and her avoidance of challenges relating to school can be seen as factors involved in the disorder. Every day, our patient trained to write for about a quarter of an hour. At the begin- ning of her stay in our clinic, her motivation to go back to school or to write on her own was very low (Addi- tional file 2). A customized wrist brace was adapted to her hand, making it easier for her to write (Figure 1). From this time she was sent to school regularly and had to participate in every exam. Our patient partici- pated in private lessons because of great difficulties in certain school subjects, which helped her to overcome her anxiety concerning school. The tremor intensity was strongly related to her individual stress level and paren- tal conflicts. By the end of the period of hospitalization, our patient’s tremor was still present, but noticeably Figure 1 Wrist brace.