REFERENCE · DIAGNOSIS

Functional Tremor

Refers to:

rhythmic or oscillating shaking of a hand, arm, leg, head, trunk or voice; and
tremor that may be intermittent, task-specific, position-dependent or persistent.

Scope boundary: Discrete non-rhythmic jerks belong on the jerks page, and a whole episodic event with altered responsiveness belongs on the functional-seizures page. Tremor techniques should not be applied to those different appearances without assessment.

Quick Reference

Functional tremor is involuntary rhythmic shaking assessed through positive movement patterns in the wider neurological examination.

Distractibility: compare the tremor during another manageable task; distinguish a clear change from ordinary fluctuation.
Entrainment: assess whether a limb tremor follows the rhythm tapped by the other limb; a pause alone is not entrainment.
Complete twelve-entry inventory: other signs, laboratory comparisons and the combined test battery, with their limits.

Understanding a positive diagnosis explains how findings fit together. Tests and investigations explains the different questions a test can answer.

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Tremor is a repeated back-and-forth shaking. It may interrupt something as ordinary as holding a cup, using a phone or bringing food to your mouth. Those examples are useful starting points for telling the clinician what matters to you; the appearance of the shaking is only part of the assessment.

A functional tremor may change when attention or movement rhythm changes. Distractibility means that the tremor becomes different, smaller or briefly absent during another task. Entrainment means that the tremor takes on the same rhythm being produced by the other hand or foot.

The clinician might ask you to do a second task while watching the shaking limb. The two comparisons answer different questions: did the shaking change, and did it actually follow the other rhythm? A clear pattern can help explain a functional diagnosis. The movement remains involuntary, including when it briefly settles. [1][2]

What the finding can tell you

It can be puzzling to have difficulty holding a cup and then see your hand become steadier during an examination. Both observations matter. One helps the clinician recognize the movement pattern; the other describes the difficulty you need help with. Ask for an explanation of the actual finding and how it relates to your symptoms.

Research suggests that attention to movement and its sensory feedback can influence functional tremor. In one experimental study, participants with functional action tremor—shaking during movement—focused differently on visual feedback from the moving hand. This is evidence about a possible contributing process, not an explanation of every person’s tremor or why it first began. [15]

Episodic, fluctuating and longer-lasting tremor

Functional tremor may be intermittent, appear in repeated bouts, fluctuate markedly through the day, or remain present for long periods. The amount of tremor can also change with posture, task, fatigue, attention, arousal or the surrounding environment. These features can help describe the pattern, but duration or fluctuation alone does not diagnose FND. [1][17]

A quieter moment in clinic may leave important questions unanswered. Tell the clinician what happens when you repeat a task, how much help you need, and whether pain or fatigue changes what you can manage later. Assessment and everyday function explains this distinction.

Other explanations and investigations

The assessment also considers other tremor conditions, such as essential tremor, Parkinson’s disease and tremor associated with dystonia (muscle contractions that pull a body part into an abnormal posture), as well as medicines and an overactive thyroid. Functional tremor can coexist with another condition. The clinician chooses investigations for a particular question; a normal scan alone does not identify functional tremor. [2][14][17]

Safety and the next step

If a familiar tremor suddenly becomes strong, first make the activity safe: put down hot, sharp or breakable objects, stop driving or another hazardous task, and sit or stabilize the affected limb if needed. For ongoing management, use the agreed recovery and flare plan.

A new or substantially changed tremor needs medical reassessment. Sudden new face or arm weakness, speech difficulty or other stroke symptoms need emergency help, even if they improve. [20]

How life is affected

The appointment should leave room for the things shaking makes difficult, including work, relationships, confidence and emotional wellbeing. Research in people with functional motor disorders, including tremor, found difficulties in daily functioning and quality of life alongside pain, fatigue and mood symptoms. These are reasons to ask about the whole person; they do not establish a psychological cause. [16]

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Before the appointment, ask what the person wants you to help explain. A short example is often enough: “The cup shakes more later in the meal, so I help carry it.” Include what they can do with support, rather than describing only what becomes difficult.

With permission, help note when tremor occurs, what the person was doing, how long it lasts and what happens afterwards. A short recording of a naturally occurring episode may help if the clinic presentation is different. Agree what is recorded and who may see it; there is no need to bring on shaking for a video. [2]

During the assessment

Help communicate any difficulty with hearing, vision, language, memory, pain or fatigue before a task begins. The person should understand what the clinician is comparing and have an agreed way to pause. If they need time to process an instruction, let that need guide the pace.

Do not repeatedly distract the person, surprise them or demand that they copy rhythms to see whether the tremor changes. Diagnostic observation belongs in a clinical assessment. At home, changes in tremor may be useful information for the person’s treatment team, but should not become surveillance or a test of credibility.

When tremor starts or intensifies

Help make the activity safe and ask what assistance is wanted. The paired recovery page contains the practical flare guidance. During assessment, the useful information is the activity, setting, duration, associated symptoms and the help or recovery time needed.

After the explanation

If the person wants, help write down which finding supported the diagnosis, which questions remain open and who will follow up. A change during the examination does not remove the need for help at home. Everyday-function assessment can connect those two parts of the conversation.

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Episodic and prolonged presentations

Characterize whether tremor is continuous, intermittent or clustered and document onset, episode duration, frequency, context, warning, functional consequences and recovery. Functional motor symptoms may be recurrent or persistent and can vary across tasks and situations. Do not make the diagnosis from episodicity, stress sensitivity or variability alone; interpret these alongside positive signs and the differential diagnosis. [1][2]

Describe distribution and activation conditions: rest with the body part supported, posture while maintaining a position, and action during movement. Look for accompanying slowness, rigidity, dystonic posturing, ataxia or other neurological findings; review medicines and relevant systemic causes. Select blood tests, imaging or other investigations for the clinical question rather than as an obligatory FND exclusion panel. [17]

Dystonic posturing: Sustained or intermittent muscle activity producing an abnormal position. Ataxia: Impaired coordination of movement.

Selecting and interpreting comparisons

Use the distractibility and entrainment pages for the actual comparisons. Document tremor behavior and performance of the second task separately. A task the person cannot understand or perform may leave the comparison indeterminate.

Most electrophysiological validation concerns limb tremor. Head, voice, trunk and standing-related shaking need phenotype-appropriate assessment; do not transfer a hand-tapping protocol or its accuracy estimates without qualification. Functional and other tremors may coexist. Neurophysiology can help when the clinical pattern remains uncertain. [14]

Diagnostic techniques at a glance

The original twelve entries remain in the full inventory. Two now have detailed drafts; the others remain brief summaries pending individual expansion. These categories overlap within laboratory protocols and are not twelve separate required tests.

The former combined outline is now explained separately in Distractibility and Entrainment.

The continuous-video brief accompanies the entrainment page; the distractibility page gives its own scope.

Function, quality of life and professional roles

Record diagnostic confidence separately from disability and participation. Neurology and general practice can explain the findings and outstanding differential questions. OT can assess how shaking affects activities and adaptations; physiotherapy can explore movement in relevant tasks. Psychological care should address the person’s needs and goals, without using distress as a diagnostic shortcut. [2][21]

Ask about reliability over time, repeated utensil or keyboard use, assistance, sensory/cognitive demands and recovery cost when relevant. These are assessment prompts, not conclusions drawn from tremor amplitude. A reduction during a dual task is not a measure of sustained safety or independence.

Gelauff and colleagues compared 160 participants with classifiable dominant functional motor symptoms, including 31 with tremor, using baseline questionnaires from an internet-intervention trial. Quality-of-life and mood measures did not distinguish the symptom groups; physical functioning differed for some groups. Referral, internet access, small subgroups and overlapping symptoms limit extrapolation. The data support broader assessment, not a disability estimate for an individual. [16]

The recovery overview owns treatment and flare-management guidance. A diagnostic comparison may inform rehabilitation, but response to treatment is not proof of diagnosis or cause.

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Evidence notes

The older review provides the clinical overview. Primary studies and the IFCN chapter support the detailed comparisons, while classification consensus frames differential assessment. The 2026 meta-analysis reports varied accuracy across electrophysiological methods and stronger performance for combined batteries; those results cannot be assigned to either bedside sign alone. [1][14][17][19]

Sources 3–13 retain their original numbers so earlier inventory citations and incoming links remain meaningful. Their presence is not a claim that every primary paper was re-reviewed in full for this stage. The two detailed drafts state their own evidence and access limits. No lived-experience quotation has been invented.

Citation table

Citation	Figure	Full citation
[1]	—	Bartl M, Kewitsch R, Hallett M, Tegenthoff M, Paulus W. Diagnosis and therapy of functional tremor: a systematic review illustrated by a case report. Neurological Research and Practice. 2020;2:35. FND-CIT-0019. https://doi.org/10.1186/s42466-020-00073-1
[2]	—	Espay AJ, Aybek S, Carson A, et al. Current concepts in diagnosis and treatment of functional neurological disorders. JAMA Neurology. 2018;75(9):1132–1141. FND-CIT-0002. https://doi.org/10.1001/jamaneurol.2018.1264
[3]	—	O’Suilleabhain PE, Matsumoto JY. Time-frequency analysis of tremors. Brain : a journal of neurology. 1998;121 ( Pt 11):2127-2134. DOI. PMID: 9827772. FND-CIT-0175.
[4]	—	Schwingenschuh P, Katschnig P, Seiler S, et al. Moving toward “laboratory-supported” criteria for psychogenic tremor. Movement disorders : official journal of the Movement Disorder Society. 2011;26(14):2509-2515. DOI. PMID: 21956485. FND-CIT-0177.
[5]	—	Schwingenschuh P, Saifee TA, Katschnig-Winter P, et al. Validation of “laboratory-supported” criteria for functional (psychogenic) tremor. Movement disorders : official journal of the Movement Disorder Society. 2016;31(4):555-562. DOI. PMID: 26879346. FND-CIT-0178.
[6]	—	McAuley J, Rothwell J. Identification of psychogenic, dystonic, and other organic tremors by a coherence entrainment test. Movement disorders : official journal of the Movement Disorder Society. 2004;19(3):253-267. DOI. PMID: 15022179. FND-CIT-0135.
[7]	—	Merchant SH, Haubenberger D, Hallett M. Mirror movements or functional tremor masking organic tremor. Clinical neurophysiology practice. 2018;3:107-113. DOI. PMID: 30215019. FND-CIT-0154.
[8]	—	Kumru H, Valls-Solé J, Valldeoriola F, et al. Transient arrest of psychogenic tremor induced by contralateral ballistic movements. Neuroscience letters. 2004;370(2-3):135-139. DOI. PMID: 15488310. FND-CIT-0121.
[9]	—	Deuschl G, Köster B, Lücking CH, Scheidt C. Diagnostic and pathophysiological aspects of psychogenic tremors. Movement disorders : official journal of the Movement Disorder Society. 1998;13(2):294-302. DOI. PMID: 9539344. FND-CIT-0176.
[10]	—	Raethjen J, Kopper F, Govindan RB, et al. Two different pathogenetic mechanisms in psychogenic tremor. Neurology. 2004;63(5):812-815. DOI. PMID: 15365128. FND-CIT-0128.
[11]	—	Kramer G, Van der Stouwe AMM, Maurits NM, et al. Wavelet coherence analysis: A new approach to distinguish organic and functional tremor types. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology. 2018;129(1):13-20. DOI. PMID: 29136548. FND-CIT-0182.
[12]	—	Lagrand TJ, Brusse-Keizer M, Charmley A, et al. A Critical Appraisal of the Whack-a-Mole and Swivel Chair Signs in the Diagnosis of Functional Movement Disorders. Movement disorders clinical practice. 2024;11(1):63-68. DOI. PMID: 38291841. FND-CIT-0181.
[13]	—	Saranza G, Vargas-Mendez D, Lang AE, Chen R. Suggestibility as a valuable criterion for laboratory-supported definite functional movement disorders. Clinical neurophysiology practice. 2021;6:103-108. DOI. PMID: 33869904. FND-CIT-0170.
[14]	—	Edwards MJ, Koens LH, Liepert J, Nonnekes J, Schwingenschuh P, van de Stouwe AMM, Morgante F. Clinical neurophysiology of functional motor disorders: IFCN Handbook Chapter. Clinical Neurophysiology Practice. 2024;9:69–77. https://doi.org/10.1016/j.cnp.2023.12.006 FND-CIT-0022.
[15]	—	Huys ACML, Haggard P, Bhatia KP, Edwards MJ. Misdirected attentional focus in functional tremor. Brain. 2021;144(11):3436–3450. DOI. Full text. FND-CIT-0220.
[16]	—	Gelauff JM, Rosmalen JGM, Gardien J, Stone J, Tijssen MAJ. Shared demographics and comorbidities in different functional motor disorders. Parkinsonism & Related Disorders. 2020;70:1–6. DOI. Authors’ institutional full text. FND-CIT-0221.
[17]	—	Bhatia KP, Bain P, Bajaj N, et al. Consensus Statement on the classification of tremors. From the task force on tremor of the International Parkinson and Movement Disorder Society. Movement Disorders. 2018;33(1):75–87. DOI. Full text. FND-CIT-0223.
[18]	—	Murgai A, Iskhakova S. Entrainment characteristics of functional tremor. Movement Disorders Clinical Practice. 2025;12(2):253–254. Published online November 4, 2024. DOI. Full text. FND-CIT-0222.
[19]	—	Rujirussawarawong S, Ounmuang C, Aungsumart S, Kasemsuk C, Limotai N. Electrophysiology in distinguishing functional tremor from organic tremor: a systematic review and meta-analysis of diagnostic accuracy. Movement Disorders Clinical Practice. Published online June 11, 2026. DOI. PubMed. FND-CIT-0224.
[20]	—	NHS. Symptoms of a stroke. Reviewed September 12, 2024; accessed September 27, 2026. Source. FND-CIT-0108.
[21]	—	Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry. 2020;91(10):1037–1045. https://doi.org/10.1136/jnnp-2019-322281 FND-CIT-0011.

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