Sauerhoefer et al. Journal of Medical Case Reports 2011, 5:158 http://www.jmedicalcasereports.com/content/5/1/158 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Severe psychogenic tremor of both wrists in a 13-year-old girl treated successfully with a customized wrist brace: a case report Elisabeth Sauerhoefer*, Caroline Schafflhuber and Oliver Kratz Abstract Introduction: Psychogenic movement disorders in childhood have been little researched. As there are few courses of treatment which have been evaluated, further examination and case studies about the treatment and clinical course of this rare occurrence of severe psychogenic tremor in childhood and adolescence are much needed. Case presentation: A 13-year-old Caucasian girl with tremor in both wrists, severe enough to prevent her from attending school, was sent to our hospital. After a complete neurological and psychiatric examination, in-patient child-psychotherapeutic treatment was started, with careful consideration given to both chronic and acute stress factors which constitute her performance and exam anxiety in school as well as the girl’s parents’ conflicted relationship. With the aid of a customized wrist brace our patient was able to go to school and write despite the presence of a marked tremor, which in turn reduced her avoidance behavior and exam anxiety. By the end of her in-patient treatment, the tremor was still noticeable, but markedly reduced in severity (reduction 80%). Two weeks after she was discharged from hospital, the tremor had completely disappeared. Conclusion: After careful clinical diagnostics, this kind of dissociative disorder should be treated appropriately with age-adapted cognitive-behavioral therapy to achieve positive and lasting benefits. Introduction Dissociative disorder is characterized by the partial or complete lack of the normally integrated functions of memories about the past, identity, perception of the environment, and control of physical movements. Diag- nostic criteria include lack of a medical condition which would explain the typical characteristics of this syn- drome and a conclusive temporal relation between the onset of dissociative symptoms and stressful events, pro- blems or needs of the patient. The International Classification of Diseases (ICD-10, chapter F: mental and behavioral disorders) lists in sec- tion F 44: dissociative disorders with impaired con- sciousness (amnesia, fugue, stupor, trance); dissociative motor disorders (paralysis, astasia, abasia, ataxia, dysar- thria, aphonia, shaking, tremor); dissociative convulsion; and dissociative anesthesia/sensory loss. * Correspondence: elisabeth.sauerhoefer@uk-erlangen.de Department of Child and Adolescent Mental Health, University of Erlangen, 91054 Erlangen, Germany Due to a lack of systematic studies, no accurate pre- diction regarding the rate of dissociative disorder during childhood and adolescence can be made. According to population-based prevalence studies using structured clinical interviews, lifetime prevalence of dissociative dis- order is estimated to be between 2-7% [1,2] in North America. Case presentation One week prior to her first visit to our clinic, the 13- year-old Caucasian girl noticed muscle twitching in her right (dominate) hand or a fluttering sensation. The muscle twitching resolved itself spontaneously after one hour. On the following day immediately before taking an exam at school, she experienced a severe tremor in her right hand which spread to her left hand and per- sisted. Immediately after leaving school, the girl was hospitalized at the neurology ward of a pediatric clinic where she underwent a complete medical check-up. After a thorough examination, no neurological or medi- cal explanation for the symptoms was found. A © 2011 Sauerhoefer et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.