Functional tic-like behaviours (FTLB; Pringsheim et al., 2023) or ‘Functional tics’ for short, occur when a person suddenly starts to experience repetitive movements and sounds that look like the tics seen in Tourette’s Disorder or Tic Disorder (DSM 5, 2013). We call the tics in Tourette’s ‘neurodevelopmental tics’ because we know they have a strong genetic basis and are due to differences in brain development. Scientists think that functional tics develop differently and are less genetically influenced.
How are functional tics and neurodevelopmental tics different?
Functional tics often start suddenly in adolescence or adulthood, whereas neurodevelopmental tics tend to start in early childhood and develop slowly over the years. Functional tics normally involve more complex, dramatic movements and sounds like self-injurious behaviour, saying whole words or swearing. Neurodevelopmental tics are usually simpler, like throat clearing or a facial twitch. There is a higher prevalence of functional tics among females.
How are functional tics diagnosed?
Diagnosing functional tics is tricky: there are no biological tests; many functional tics look like neurodevelopmental tics; and people can have both functional and neurodevelopmental tics. Even more confusing for people with functional tics, there isn’t a separate diagnosis called ‘Functional Tic Disorder’. Functional tics are considered to be a type of Functional Neurological Symptom Disorder (FND), according to the main diagnostic textbook health professionals use, the DSM-5 (2013).
As Functional Neurological Disorder (FND) includes many varied symptoms, including seizures or mobility problems, experts felt the term was too general. The European Society for the Study of Tourette Syndrome therefore proposed alternative diagnostic criteria (Pringsheim et al., 2023). Diagnosis typically involves clinical observation and history-taking by an experienced clinician. If symptoms started after the age of 12, rapidly developed and had at least four of the following nine symptoms, then a diagnosis of functional Tic-Like Behaviours is given:
- More complex than simple tics
- Tics are inconsistent, rather than sterotyped
- Complex tics are often dramatic, may involve self-injurious behaviour and are context-dependent
- Tics don’t follow the usual path of development from head down to body
- Vocal tics are complex and context-dependent with many words and statements
- Cultural and social influences evident in tics
- Symptom intensity varies a lot in a short space of time
- New tics come and go all the time
- On physical examination by a doctor, tics increase
As well as asking about the factors above, a clinician diagnosing functional tics will ask about what was happening in the person’s life at the time the functional tics developed. If there are other psychological difficulties, and several stressors in their life at the time the tics developed, then a functional, rather than a neurodevelopmental basis to the tics is suspected. During the stresses of the Covid lockdown, there was an explosion of people developing tics and even ‘tic attacks’, with high-profile social media influencers providing an important way to share experiences and normalise the condition, although arguably also potentially fuelling this ‘tic pandemic’ (Hull and Parnes, 2021).
How are functional tics treated?
Treatment for functional tics is different than for neurodevelopmental Tics. Medicine or behavioural treatments designed for Tourette’s like Exposure and Response Prevention (ERP) or Comprehensive Behavioural Intervention for Tics (CBiT) are unlikely to be helpful for someone with functional tics. Approaches like CBT may be more effective at helping the person to manage their symptoms, firstly by understanding what’s wrong and then retraining the brain using psychological techniques. Tourette’s Action’s leaflet on functional tics describes psychological strategies that may be helpful. The Neurosymptoms website written by a neurologist, is helpful for understanding the brain basis of functional tics and their appropriate treatment.
For people seeking help, it’s essential to seek support from a healthcare professional familiar with Tourette’s and functional neurological disorders. A therapist who validates the individual’s experience of tics and their symptoms is likely to be more helpful than someone who implies ‘it’s all in your mind’, a frankly disrespectful and inaccurate message to give.
At NeuroDiverse Online we have a team of highly qualified psychologists and other health professionals who can conduct diagnostic assessments and therapies for Tourette’s and functional tics. Get in touch today to book your appointment.
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