FND Education Project

REFERENCE · DIAGNOSIS

Functional Tics and Tic-Like Symptoms

Refers to: Assessed functional motor movements and vocal/phonic tic-like symptoms: sounds, throat clearing, words, phrases or combinations of movement and sound. Readers may call these functional tics, tic-like behaviours (FTLBs) or verbal tics. The research word “behaviours” does not mean intentional action.

Scope boundary: Tics are not another name for functional jerks, speech or voice impairment, or cough. Tourette syndrome and other primary tic disorders need their own assessment and may coexist with functional tic-like symptoms. A new sound or word does not by itself establish which diagnosis applies.

Diagnostic techniques at a glance

Featured approach: Specialist assessment of the symptom history, developmental course and overall clinical pattern.
Diagnostic method: Explain the positive clinical reasons for the formulation and their limits. No single movement, demographic feature or normal test establishes functional tic-like symptoms.
Media needed: A captioned consultation diagram showing movement and sound, possible coexistence and the questions used in assessment. Do not provoke symptoms for a demonstration.

Diagnostic techniques at a glance

These brief entries describe signs, observations, criteria and investigations clinicians may consider. They are not a checklist of tests everyone needs. Evidence and limitations differ for each entry; a positive sign must fit the whole clinical picture, including possible coexisting disease.

The longer explanations already on this page remain below. Individual technique pages will be developed and reviewed separately.

Developmental and onset history

The clinician compares childhood tic history, onset speed and progression. Rapid emergence of complex symptoms can contribute to a functional formulation, but no onset pattern, age or gender determines the diagnosis alone. Earlier primary tics may coexist. [2][3]

Motor and vocal phenomenology

The assessment describes movements, sounds and phrases, their complexity and evolution. Observational cohorts identify group differences, but individual overlap with Tourette syndrome is substantial. Coprolalia or a complex phrase alone cannot establish functional symptoms. [3][6]

Context dependence and variability

Symptoms are compared across ordinary settings and tasks using history and respectful observation. Context sensitivity occurs in both functional and primary tics, so changes with attention or an audience are not independently diagnostic. [2][3]

Suppressibility

The clinician asks about temporary ability to delay symptoms rather than demanding a prolonged demonstration. Both diagnoses can include suppressibility or difficulty suppressing. This is a history feature with limited individual discriminative value. [2][3]

Premonitory sensations

An urge or sensation before movement or sound is documented in the person’s own words. Its presence or absence contributes context but does not reliably divide functional from primary tic disorders, particularly across ages. [2][3]

Suggestibility

Symptoms may change when discussed or observed. This can occur in both functional and primary tics and is not proof of deliberate imitation. Avoid provoking symptoms to demonstrate it; use the history when discussion itself is difficult. [2][3]

ESSTS consensus criteria

The framework combines clinical history and phenomenology rather than relying on a single sign. Its original publication was expert consensus, not prospective diagnostic-accuracy validation. Apply alongside the published critique and an assessment for coexistence. [2][3]

Longitudinal reassessment

Follow-up, childhood records and consensual collateral information can clarify mixed or uncertain presentations. A changing formulation is preferable to forcing a binary classification. This is a clinical process, not an independently validated positive sign. [3][7]

Neurophysiology and other investigations

EEG–EMG may address a differential with jerks, but premovement potentials also occur in primary tics. There is no established high-accuracy laboratory test that independently separates functional tic-like symptoms from Tourette syndrome. Other tests answer specific differential questions. [8][9]

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For the Person With FND

An unexpected sound or word can leave you worrying about what other people heard and what they think you meant. You deserve an explanation and practical help. Recognizable words can still be involuntary; their content is not a reliable account of your wishes or beliefs.

Motor tic-like symptoms involve movements. Vocal or phonic symptoms involve sounds, which may or may not be words. Some people experience both. There can be a sensation or urge before a symptom, but not everyone notices one. Symptoms may change over time. Becoming vocal does not, on its own, show that symptoms are functional or that they are Tourette syndrome. 1, 5

You may encounter coprolalia (involuntary socially inappropriate or taboo words), echolalia (repetition of another person’s words) or palilalia (repetition of one’s own words). These descriptions do not determine the diagnosis. Coprolalia is not required for Tourette syndrome and is not unique to it. 5

What an assessment can offer

A clinician with tic and FND experience asks when symptoms began, how they developed, whether there were earlier tics, what movements or sounds occur, and how life is affected. They may review a recording made with consent, if one already exists or can be obtained safely. Tests depend on the possibilities being considered; normal results alone do not prove FND. 1, 2

Functional tic-like symptoms and a primary tic disorder can occur together. A useful explanation should tell you which features support each part of the diagnosis and what remains uncertain. You can ask: “What makes this the best explanation, and what would make us review it?” 1, 3

What this page cannot tell you: It cannot classify your symptoms from a description, a video or a checklist. Sudden onset, complex phrases, an urge, difficulty holding symptoms back, your age or gender, or seeing tics online cannot decide the diagnosis alone. Please do not deliberately provoke symptoms or test how long you can suppress them.

When the pattern changes

Follow the agreed plan for familiar symptoms. Ask for reassessment when new sounds or movements persist or substantially change the pattern. Seek urgent help for serious injury, breathing or swallowing danger, new weakness or other acute neurological change, marked confusion, or a possible serious medication reaction. Do not assume every new symptom is part of an established FND diagnosis.

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For Family, Friends, and Other Supporters

Believe that the symptom is happening without the person choosing it. Ask how they want you to respond to a sound or phrase, especially in public. They may prefer a brief acknowledgment and then time to finish their intended message. Avoid demanding an apology for involuntary words, asking them to demonstrate symptoms, or repeatedly testing whether they can stop.

For a consultation, a short description of the sequence and its impact may be more useful than a large symptom log. Record only with consent and never at the expense of safety. A quiet appointment, breaks or written information may help someone for whom discussing symptoms is difficult.

Do not use online examples, a psychiatric history or a social-media habit to decide the diagnosis yourself. These can be discussed respectfully as context; none establishes that the person is copying deliberately. 1

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For Clinicians and the Care Team

Assess onset and longitudinal course, childhood motor/vocal history, family history, phenomenology, urges, suppressibility, context, medications/substances, other neurological findings and functional impact. Consider Tourette syndrome, persistent motor or vocal tic disorder, provisional tic disorder, stereotypies, compulsions, myoclonus, dystonia, epileptic events and medication or other medical causes as indicated. Document coexisting primary and functional symptoms where appropriate. 1, 5

The 2023 ESSTS criteria provide an expert-consensus framework, not a prospectively validated diagnostic-accuracy test in that publication. Consider the entire clinical pattern rather than treating abrupt onset, age, sex/gender, complex vocalizations or social exposure as decisive. A 2024 critical review questions aspects of the diagnostic literature, including circular reasoning and clinical benchmarks. Communicate these limits while offering care and follow-up. 2, 3

Do not transfer the diagnostic significance of tremor entrainment or jerk neurophysiology directly to tic-like symptoms. Stress, trauma, anxiety, autism and ADHD are not diagnostic prerequisites. Assessment should cover adults as well as young people; much rapid-onset research concerns younger clinic populations.

Media contributor brief

Use a fictional consultation or static diagram, with captions and a full text equivalent. Show routes for motor symptoms, vocal symptoms and coexistence. Explain why history and longitudinal assessment matter. Avoid symptom montages, provocative exercises, offensive example phrases and any visual suggestion that movement shape alone distinguishes diagnoses.

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Research and Sources

The review and assessment guideline support terminology and individualized evaluation. Consensus criteria and their published critique are presented together so uncertainty remains visible. The treatment case series is linked for context; response to treatment is not a diagnostic test.

Citation Full citation and evidence limit
[1] Malaty IA, Anderson S, Bennett SM, et al. Diagnosis and management of functional tic-like phenomena. Journal of Clinical Medicine. 2022;11(21):6470. FND-CIT-0110. Source. Expert review; diagnostic formulation and individualized management. The review reported no controlled treatment studies specific to functional tic-like symptoms.
[2] Pringsheim T, Ganos C, McGuire JF, et al. European Society for the Study of Tourette Syndrome 2022 criteria for clinical diagnosis of functional tic-like behaviours: international consensus from experts in tic disorders. European Journal of Neurology. 2023;30(4):902–910. FND-CIT-0111. Source. Expert Delphi consensus. The publication explicitly states that prospective sensitivity and specificity testing was lacking; not a validated self-diagnostic checklist.
[3] Andersen K, Cavanna AE, Szejko N, et al. A critical examination of the clinical diagnosis of functional tic-like behaviors. Movement Disorders Clinical Practice. 2024;11(9):1065–1071. FND-CIT-0112. Source. Critical review of diagnostic reasoning, clinical benchmarks and coexistence. Supports transparent uncertainty, not dismissal of symptoms.
[4] Maxwell A, Zouki JJ, Eapen V. Integrated cognitive behavioral intervention for functional tics (I-CBiT): case reports and treatment formulation. Frontiers in Pediatrics. 2023;11:1265123. FND-CIT-0113. Source. Uncontrolled case series of eight young people. Reported improvement cannot establish causal efficacy, comparative benefit or generalizability to other populations.
[5] Szejko N, Robinson S, Hartmann A, et al. European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part I: assessment. European Child & Adolescent Psychiatry. 2022;31:383–402. FND-CIT-0114. Source. Primary tic-disorder assessment guideline; adjacent evidence for terminology and differential diagnosis, not functional-tic treatment evidence.
[6] Pringsheim T, Ganos C, McGuire JF, et al. Rapid Onset Functional Tic-Like Behaviors in Young Females During the COVID-19 Pandemic. Movement disorders : official journal of the Movement Disorder Society. 2021;36(12):2707-2713. DOI. PMID: 34387394. FND-CIT-0173.
[7] Cavanna AE, Caimi V, Capriolo E, et al. Neurodevelopmental Tics with Co-Morbid Functional Tic-like Behaviors: Diagnostic Challenges of a Complex Tourette Syndrome Phenotype. Brain sciences. 2025;15(5):435. DOI. PMID: 40426606. FND-CIT-0172.
[8] van der Salm SM, Tijssen MA, Koelman JH, van Rootselaar AF. The bereitschaftspotential in jerky movement disorders. Journal of neurology, neurosurgery, and psychiatry. 2012;83(12):1162-1167. DOI. PMID: 22952323. FND-CIT-0125.
[9] Edwards MJ, Koens LH, Liepert J, et al. Clinical neurophysiology of functional motor disorders: IFCN Handbook Chapter. Clinical neurophysiology practice. 2024;9:69-77. DOI. PMID: 38352251. FND-CIT-0022.

Evidence check: September 17, 2026 · Human, clinical, lived-experience and accessibility review pending.

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