Functional Movement Disorders

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Functional movement disorders

Author: Sarah C Lidstone, MD, PhD
Section Editor: Howard I Hurtig, MD
Deputy Editor: April F Eichler, MD, MPH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2022. | This topic last updated: Aug 17, 2022.
INTRODUCTION
Functional movement disorder (FMD) is a subtype of functional neurologic symptom disorder

(conversion disorder) in which the primary manifestation is tremor, dystonia, gait disorder, or
other abnormal movement. Patients with FMD have neurologic symptoms that are
incongruent with known neurologic disease but are nevertheless genuine and cause distress
and/or psychosocial impairment [1].
FMD is common in clinical settings, but the diagnosis is often delayed or missed, and
prognosis for complete remission is generally poor. Over time, more emphasis has been
placed on physical examination signs to guide diagnosis and use of evidence-based
treatments, including physiotherapy and multidisciplinary rehabilitation.
This topic reviews the epidemiology, etiology and pathogenesis, clinical features, diagnosis,
treatment, and prognosis of FMD. Functional neurologic symptom disorder more broadly, as
well as other subtypes (eg, functional weakness and nonepileptic seizures), are discussed
elsewhere:
(See "Conversion disorder in adults: Epidemiology, pathogenesis, and prognosis".)

(See "Conversion disorder in adults: Clinical features, assessment, and comorbidity".)
(See "Conversion disorder in adults: Treatment".)
(See "Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis".)
(See "Psychogenic nonepileptic seizures: Management and prognosis".)
TERMINOLOGY
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FMD is a subtype of functional neurologic symptom disorder (conversion disorder)

( table 1). Although conversion disorder is the term used by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) [1], functional neurologic symptom
disorder has become preferred by many because it is etiologically neutral and usually
acceptable to patients [2]. Older terms, including psychogenic, hysterical, and nonorganic,
have fallen out of favor. (See "Conversion disorder in adults: Terminology, diagnosis, and
differential diagnosis".)
Subtypes of functional neurologic symptom disorder recognized by DSM-5 include (from

most to least common):
Nonepileptic seizures
Weakness and paralysis
Abnormal movement
Speech symptoms
Globus sensation (swallowing symptoms)
Sensory symptoms
Cognitive symptoms
The International Classification of Diseases, 11th Revision (ICD-11) uses the term "dissociative
neurological symptom disorder" for the DSM-5 diagnosis of functional neurologic symptom
disorder [3]. Older versions used the term "dissociative disorders." (See "Conversion disorder
in adults: Terminology, diagnosis, and differential diagnosis".)
EPIDEMIOLOGY
Population rates of FMD are not known, and most studies are small and drawn from clinical
settings focusing on specific phenotypes. The incidence of functional neurologic symptom
disorder more broadly is reviewed separately. (See "Conversion disorder in adults:
Epidemiology, pathogenesis, and prognosis", section on 'Epidemiology'.)
Prevalence in clinical settings – FMD accounts for 2 to 10 percent of patients in

movement disorder clinics [4-7]. The prevalence of FMD among patients who present
with dystonia and fixed, contracted joints may be even higher. As an example, one
prospective study of 41 such patients reported that criteria for functional dystonia were
fulfilled in 15 (37 percent) [8]. (See 'Functional dystonia' below.)
Age of onset – FMD usually begins in middle adulthood but can affect children as
young as six years and older adults [6,9-11]. The mean age at presentation is 40 years
[12].

Sex ratio – Females are affected more often than males in both children and adults. In
large cohort studies, the percentage of females ranges from 60 to 90 percent [12-15].
However, the sex preponderance may vary by phenotype; as an example, functional
myoclonus and functional parkinsonism appear to have similar frequency in males and
females [16].
Phenotype frequency – Functional tremor is the most frequent FMD phenotype,

followed by functional dystonia [9,15-19]. Approximately one-quarter of patients have a
mixed phenotype. A meta-analysis that included nearly 5000 cases of FMD reported the
following phenotype frequencies: mixed FMD (23 percent), tremor (22 percent),
weakness (18 percent), dystonia (12 percent), gait disorder (8 percent), myoclonus/jerks
(5 percent), and parkinsonism (2 percent) [20].
ETIOLOGIC FACTORS
FMD, like other functional neurologic symptom disorders, is best conceptualized using a
biopsychosocial model of predisposing, precipitating, and perpetuating factors. Factors can
be biologic, psychological, or social, and the combination of factors is unique to each patient
( table 2). None of the factors is individually causal; rather, their presence increases risk of
developing the disorder.
Predisposing factors – Common risk factors for developing FMD include:
• Female sex
• Younger age
• Emotional and personality disorders
• Neurologic disease/symptoms
• Coexistence of other health issues
• Difficulties in interpersonal relationships
• Psychiatric illness
Stressful life events and maltreatment are substantially more common in people with
functional neurologic symptom disorder than in unaffected controls [21]. Emotional
neglect is more common than traditionally emphasized sexual and physical abuse, but
many patients report no stressors. Some studies have found higher rates of childhood
trauma in patients with FMD compared with sex-matched controls, while others have
not [4,22-28]. Exposure to functional or organic movement disorders among friends
and family (disease modeling) may also be a risk factor for developing FMD [11,29].
There is emerging evidence that genetic factors may act as predisposing factors and
may interact with environmental factors such as childhood adverse events. A study of

single-nucleotide polymorphisms from 14 candidate genes among patients with FMD

identified a polymorphism of the tryptophan hydroxylase 2 (TPH2) gene, which
predicted younger age at symptom onset, interaction with childhood trauma resulting
in greater symptom severity, and reduced connectivity between right amygdala and
middle frontal gyrus [30]. Additional factors, such as the nature and timing of stressful
events, may influence their role as risk factors in adulthood. (See "Conversion disorder
in adults: Epidemiology, pathogenesis, and prognosis", section on 'Premorbid clinical
factors'.)
Precipitating factors – A precipitating factor occurring in close temporal proximity with

symptom onset can be identified in 50 to 80 percent of patients with FMD. In some
cases, symptoms of panic attack are present during the precipitating event [27].
Examples of precipitating factors include [27,31]:
• Physical injury or accident

• Surgery, medical procedure, or medical illness
• Emotional event
• Neurologic disorder (eg, severe migraine, brachial neuritis, Bell's palsy, vertigo,
carpal tunnel syndrome)
Perpetuating factors – Factors that, if present, may perpetuate FMD symptoms are
important to identify, particularly those that are modifiable. Common perpetuating
factors include [28,32,33]:
• Pain
• Physical deconditioning
• Ongoing psychosocial stress related to family, work, or school
• Untreated anxiety
• Intercurrent illness
• Illness beliefs regarding an alternate diagnosis (may or may not be modifiable)
• Comorbid psychiatric disorders
• Disability-related financial benefits
• Litigation
• Life stress that was relieved by onset of the disorder and would likely recur if the
patient were to recover
Cognitive-behavioral, neurobiologic, and psychodynamic hypotheses that attempt to explain

how functional symptoms develop in the context of these factors are reviewed in more detail
separately. (See "Conversion disorder in adults: Epidemiology, pathogenesis, and prognosis",
section on 'Hypotheses'.)

PATHOGENESIS
FMD is a complex neuropsychiatric condition, and underlying mechanisms are an intense

area of study [34]. Processes relevant to FMD include [35-40]:
Abnormal self-directed attention

Abnormal beliefs and expectations
Abnormal sense of agency (ie, a subjective sense of control) for self-generated
movements
Motor learning and plasticity
Abnormal limbic-motor interface
Research has sought to understand the neural mechanisms by which functional movement
symptoms emerge, using predictive coding models of how the brain generates a sense of
agency [41]. At their core, functional motor symptoms are experienced as involuntary,
related to a loss of sense of agency due to mismatch between feedforward signals through
the "agency network" (involving the right temporoparietal junction) and feedback sensory
information once movement is executed. This mismatch arises due to overweighting of the
feedforward message, which is strongly influenced by expectation, enhanced attention, and
emotion [36]. In other words, incoming afferent information is overwhelmed by "top-down"
prior signals [35,42]. In patients with alexithymia (difficulty identifying and expressing
emotion) or a tendency to somatize, emotional or autonomic symptoms that occur with a
triggering event may be misinterpreted as being caused by a physical illness [38].
Subtle structural and functional differences between individuals with FMD and controls have
been demonstrated using advanced imaging techniques. As an example, an observational
study using magnetic resonance imaging (MRI) voxel-based morphometry analysis showed
increased gray matter volume in left amygdala, left striatum, left cerebellum, left fusiform
gyrus, and bilateral thalamus and decreased volume of left sensorimotor cortex among 35
patients with FMD compared with 35 unaffected controls, irrespective of clinical
phenomenology [43]. However, other smaller studies have shown a different set of cerebral
abnormalities, perhaps due to variations in methods of analysis. Similar work by the same
group demonstrated impaired self-agency (the ability to control one's actions) using
functional MRI, which showed a lack of connectivity between the right temporoparietal
junction and sensorimotor cortex [40].
CLINICAL FEATURES
Shared features — FMD very often begins abruptly, regardless of phenotype ( table 3)

[12]. In a cohort of 50 patients with FMD, 54 percent of patients reported sudden onset

within seconds to minutes, while 36 percent developed symptoms over the course of hours
to one day [27]. By contrast, other movement disorders typically begin gradually and without
provocation, except when the underlying cause is an acute illness such as a stroke.
Progression to maximum symptom severity and disability is often rapid, which is uncommon
in other movement disorders. Illness, surgery, and physical injuries are common precipitants,
including minor injuries (eg, lifting a moderate weight or following a nonconcussive motor
vehicle accident). Often more than one type of movement disorder is present, which can be a
helpful clue to the diagnosis.
Once FMD is established, abnormal movements can be present constantly or occur as

discrete episodes with periods of normal functioning. Patients very often describe "good
days and bad days," with variation in their function accordingly. Pain, fatigue, and cognitive
symptoms are often present at a constant low level or may be the dominant symptom in
some patients. Disability and unemployment due to functional symptoms or other health
concerns are common but not universal.
Trials of medications and other therapeutic interventions for movement disorders have
variable results in FMD, and symptoms may be much more or much less responsive than
would be expected. Examples include complete remission of Parkinson-like symptoms with
herbal remedies [44] and immediate resolution of fixed dystonia with injections of botulinum
toxin, even though the neuromuscular blocking effect of botulinum toxin requires at least 72
hours before a clinical impact can be observed [45]. Lack of response to carbidopa-levodopa
for suspected Parkinson disease should be interpreted cautiously, as poor responses can
also be characteristic of atypical parkinsonism.
Functional tremor — Functional tremor is the most common type of FMD. Tremor is defined
as a rhythmic and oscillatory movement of a body part with a relatively constant frequency.
(See "Overview of tremor".)
Functional tremor typically occurs with rest, posture, and action. Any body part may be
involved, but hand tremor, leg tremor, and whole-body tremor are common sites [46]. A
feeling of "internal" tremor is common although not specific to FMD. In the upper limbs, the
fingers are often spared, with much of the tremor occurring at the wrist [18,47].
There are numerous positive signs of functional tremor, including hallmark signs of
distractibility, variability, and entrainability.
Distractibility – Distractibility refers to complete remission or temporary suspension of

the tremor with a cognitive or motor task. A common distraction maneuver is to ask the
patient to hold the arms outstretched, and once the tremor is established, ask the
patient to count through each of their fingers in order on the contralateral hand. Other

potent distraction techniques include the history portion of the assessment and
standard cranial nerve examination [48]. (See 'Distractibility' below.)
Variability – Variability manifests as changes in tremor distribution, direction,

frequency, and amplitude at different time points during the assessment, or over time
on history. (See 'Variability' below.)
Entrainment – Entrainment refers to a shift of tremor frequency to match an externally

or internally directed competing rhythmic movement with another body part. Some
patients can "self-entrain" to stop their own functional tremor. Entrainment can also be
demonstrated electrophysiologically in selected cases. (See 'Electrodiagnostic testing'
below.)
Co-contraction – Patients with functional tremor may have isometric contraction of

antagonist muscles in the tremoring body part. This ongoing co-contraction may be
perceived on examination as increased muscle tone during passive movement [47].
"Whack-a-mole" sign – Movement suppression of one body part (eg, holding an

individual's wrist) may be followed by immediate re-emergence of movement in
another body part [49,50].
Response to weight load – Functional tremor may increase in amplitude with weight
load [51,52].
Pause with ballistic movement – Tremor may temporarily arrest, followed by ballistic
movement of the contralateral arm.
Electrophysiologic studies may be helpful in distinguishing functional tremor in challenging

cases with inconsistent or hard-to-elicit positive signs. (See 'Electrodiagnostic testing' below.)
Functional dystonia — Functional dystonia is the second most common type of FMD.

Dystonia refers to sustained or intermittent muscle contractions causing abnormal, often
repetitive movements, postures, or both. Dystonic movements are typically patterned and
twisting, and may be accompanied by tremor, which is usually slow and irregular. Dystonia is
often initiated or worsened by voluntary action and associated with unintentional muscle
contraction (overflow muscle activation). (See "Etiology, clinical features, and diagnostic
evaluation of dystonia", section on 'Clinical features'.)
Functional dystonia is often described by the patient as "spasms" and may affect any part of
the body (focal) or multiple areas at once (generalized). Clinical features and positive signs
fall into three main phenotypes:
Fixed focal postures – Common focal presentations of functional dystonia include fixed
plantarflexion/inversion of the ankles and fixed finger flexion sparing the pincer grasp.
Fixed postures are rare in nonfunctional dystonia. Patients typically display marked
resistance to passive movement when the limb is at rest. Pain and sensory disturbances
are often present, although not always. In severe cases, muscle atrophy or joint
contractures may be present due to disuse or prolonged maintenance of the tonic
posture.
Most cases of dystonia after peripheral trauma are probably examples of functional
focal dystonia [8,53]. The entity may be termed peripherally induced dystonia, fixed
dystonia, traumatic or posttraumatic dystonia, posttraumatic cervical dystonia,
posttraumatic painful torticollis, causalgia-dystonia syndrome, and complex regional
pain syndrome dystonia (formerly reflex sympathetic dystrophy dystonia) [8,53-59]. In
most cases, the precipitating trauma is minor. The inciting injury may involve nerve
root, peripheral nerve, or soft tissue. Although the mechanism is controversial [60-66],
there is little evidence to support an organic basis, while the overlap with FMD features
is extensive [54].
Positive signs include the presence of a fixed posture typical of functional dystonia,
dramatic/immediate resolution with interventions (eg, physiotherapy, placebo, low-
dose botulinum toxin injection), and lack of dynamic features such as overflow or a
sensory trick. (See "Etiology, clinical features, and diagnostic evaluation of dystonia",
section on 'Dynamic and temporal features'.)
Functional cranial dystonias – Functional facial spasms are a common subtype of

functional dystonia. Concomitant jaw pain is common, and dental procedures are a
trigger in some patients. Facial spasms may be solitary or occur in combination with
episodic generalized dystonic spasms. Platysma overactivation is often present and may
be misinterpreted as lower facial weakness, such as a facial droop seen in stroke.
Functional facial dystonia is remarkably consistent between individuals with
recognizable features [67].
A case series of 61 patients with facial FMD showed episodic or sustained muscular
spasms resembling dystonia in all patients, most commonly involving the lips (61
percent), eyelids (51 percent), perinasal region (16 percent), and forehead (10 percent)
[67]. The most common pattern consisted of tonic, sustained, lateral, and/or downward
protrusion of one side of the lower lip with ipsilateral jaw deviation ( picture 1). More
than half of patients had ipsi- or contralateral tonic eye closure and excessive platysma
contraction in isolation or combined with fixed lip dystonia. Spasms were reported as
painful in 25 percent.
Positive signs of functional facial spasms include downward lip-pulling, orbicularis oculi
spasm, jaw deviation, and platysma overactivation. Signs that can help distinguish
functional facial movements from those of tardive dyskinesia include lack of chewing
movements or self-biting, lingual movements without mouth movements, and the

presence of abnormal speech. (See "Tardive dyskinesia: Etiology, risk factors, clinical
features, and diagnosis", section on 'Oro-bucco-lingual and facial dyskinesia'.)
Other common patterns include constant tonic eye closure, constant bilateral eye
closure with the absence of prominent muscle activity (resembling ptosis), and
contraction of corrugator and procerus muscles casing a narrowed palpebral fissure
without involvement of orbicularis oculi.
Paroxysmal mixed dystonia – The most common form of generalized functional

dystonia is paroxysmal mixed dystonia. These are nonstereotyped episodes, which
often have mixed movements that do not conform to a single phenomenology (ie,
elements of dystonia, ataxia, chorea, and ballism). Associated symptoms of pain or
dissociative-like symptoms are common. Episodes may share overlapping features with
nonepileptic seizures [68].
Functional gait — Functional gait disorders can occur as an isolated FMD or in combination

with other FMD phenotypes. Examples of mixed FMD include functional leg weakness
causing a leg-dragging gait and functional fixed lower-limb dystonia causing a dystonic gait
[69].
Numerous functional gait patterns have been described, including [31,70-73]:
Excessive slowness and stiffness

Knee-buckling gait
Leg-dragging gait
Dystonic gait
Astasia-abasia, an inability to stand (astasia) or walk (abasia)
"Walking on ice"
Uneconomic gait
Bizarre gait (ie, not conforming to any of the usual patterns observed with neurologic
gait disorders)
Maintenance of postural control on a narrow base with flailing arms and excessive
trunk sway
Knowledge of gait patterns is essential in diagnosing functional gait disorders. The mere
presence of a cautious gait does not confirm a functional etiology. A cautious gait may be a
legitimate psychological adaptation, based upon an appropriate response to real or
perceived disequilibrium [74]. In addition to appropriate caution and fear of falling, the
differential diagnosis of cautious gait includes higher-level frontal (apraxic) gait disorders.
(See "Causes and evaluation of neurologic gait disorders in older adults", section on 'Frontal
(apraxic) gait'.)

Bizarre gait patterns are also not always functional and may be seen in patients with
dystonia syndromes. In these cases, the diagnostic clue of a functional etiology is variability,
or the inconsistency of the bizarre functional gait. By contrast, dystonic gaits will be
consistently "bizarre" (ie, the same gait pattern is consistently repeated and the same deficits
present at the same point in the gait cycle) [75]. An exception to this consistency occurs in
patients with lower-limb dystonia, who may appear to have a foot drop when walking
forward but not backward (when the dystonia consistently resolves).
Positive signs for functional gait include dragging monoplegic gait, huffing and puffing,
falling toward support, excessive slowness, hesitation, noneconomic posture, and knee-
buckling [76-78]. Asking a patient with gait disorder to propel themselves forwards and
backwards in a rolling chair while sitting can aid in the assessment of improvement in
functional gait; the adoption of a normal walking-like pattern while seated may be a positive
sign [79,80].
Functional myoclonus — Myoclonus is a brief, shock-like muscle contraction (positive

myoclonus) or a sudden lapse in tone (negative myoclonus or asterixis) of the affected body
part. Patients will usually describe myoclonus as consisting of "jerks," "shakes," or "spasms."
Myoclonic movements have many possible etiologies and pathophysiologic features. (See
"Classification and evaluation of myoclonus".)
Functional myoclonus may be underrecognized in patients presenting with sudden body

jerks, particularly when they involve the trunk or axial muscles. In one systematic review of
179 published cases identified as having propriospinal myoclonus, functional myoclonus was
diagnosed in 57 percent [81]. Characteristics that suggest functional myoclonus include [82]:
Inconsistent character of the movements (amplitude, frequency, and/or distribution)

Associated functional symptomatology
Marked reduction of the myoclonus with distraction
Spontaneous periods of remission
Acute onset and sudden resolution
Evidence of underlying psychopathology
Positive signs for functional myoclonus/jerks, as with tremor, include variability and
distractibility. The localization can help diagnostically, as functional jerks are often axial when
other types of myoclonus occur in the limbs. Arrhythmic jerks of the trunk, hips, and knees,
classically recognized as propriospinal myoclonus, can also be functional when positive signs
are present (distractibility, variability) [4]. (See 'Distractibility' below and 'Variability' below.)
Electrodiagnostic testing can be helpful in differentiating functional myoclonus from other

myoclonus. (See 'Electrodiagnostic testing' below.)

Functional parkinsonism — The cardinal motor manifestations of parkinsonism are rest

tremor, bradykinesia, rigidity, and postural instability (see "Clinical manifestations of
Parkinson disease", section on 'Cardinal features'). Manifestations of functional parkinsonism
can be superficially similar but have features suggesting a functional origin, including the
presence of other functional signs and symptoms [83].
Tremor – The tremor of functional parkinsonism shares the characteristics of isolated

functional tremor (see 'Functional tremor' above), manifesting as a complex resting,
postural, and action tremor with abrupt onset, a static course, and changeable features
[31,84-86]. Movements may include violent shaking of one arm or generalized violent
shaking [83]. The tremor will typically increase with attention and decrease with
distraction [46].
Bradykinesia – Functional bradykinetic movements are slow and effortful but lack the
typical decrement in speed or amplitude that is observed with successive movements in
true bradykinesia (ie, slowing without decrement).
Rigidity – A functional increase in muscle tone is the result of gegenhalten/paratonia

rather than true rigidity (ie, involuntary resistance to passive movement). Cogwheeling
is absent. Of note, gegenhalten can also be seen in older adults, especially those with
dementia.
Postural instability – Atypical gait abnormalities and postural instability are often
present in functional parkinsonism. Postural stability testing may reveal positive signs
such as arm-flailing and reeling backward without falling.
In patients who have been exposed to carbidopa-levodopa as a trial, lack of a response may
be suggestive of functional parkinsonism (although atypical parkinsonian syndromes are
also poorly responsive to levodopa). On the other hand, many patients with functional
parkinsonism have complete symptom resolution with levodopa due to a placebo effect.
Importantly, features of functional parkinsonism may coexist with Parkinson disease, and
some evidence suggests that functional parkinsonism can be an early manifestation of
Parkinson disease [83,87,88]. Patients with functional parkinsonism should be followed
longitudinally to examine for emerging Parkinson disease. A helpful distinguishing historical
feature is that functional parkinsonism will not present with a prodrome suggestive of alpha-
synuclein pathology (eg, constipation, depression, anosmia, or rapid eye movement [REM]
sleep behavior disorder), as seen in most patients with Parkinson disease. A notable
exception is tremor-dominant Parkinson disease, which may not display these features
either, at least in the early stages. (See "Clinical manifestations of Parkinson disease".)
Knowledge of atypical parkinsonian disorders is also crucial in some cases to avoid

misdiagnosis. As an example, a patient presenting with a very symmetric akinetic rigid
syndrome without tremor may be erroneously diagnosed with functional parkinsonism. In

fact, such a presentation is common among other parkinsonian syndromes such as multiple
system atrophy and progressive supranuclear palsy. (See "Multiple system atrophy: Clinical
features and diagnosis" and "Progressive supranuclear palsy (PSP): Clinical features and
diagnosis" and "Corticobasal degeneration".)
A normal dopamine transporter imaging study using single-photon emission computed

tomography (SPECT) scan is helpful for supporting a diagnosis of either functional, drug-
induced, or vascular parkinsonism, rather than nigrostriatal degeneration [89]. However,
scans can change from normal to abnormal over time, and, therefore, a single test should
not be used to support a diagnosis of FMD. (See 'Neuroimaging' below and "Diagnosis and
differential diagnosis of Parkinson disease", section on 'DaTscan'.)
Functional tics — Tics are recurrent, semivoluntary, stereotyped movements that can be

either vocal or motor, simple or complex. There is a narrow repertoire of tics in an individual,
which may change over time. Tics are accompanied by a premonitory urge to perform the
movement, discomfort if the tic is contained, and relief after the tic is performed. Tics are
common in children, with a prevalence of 6 to 12 percent. (See "Hyperkinetic movement
disorders in children", section on 'Tic disorders'.)
Functional tics are challenging to diagnose, largely because nonfunctional tics have many of
the same clinical characteristics. Many of the shared features that help differentiate FMD
from other movement disorders (eg, sudden onset, distractibility, suggestibility, temporary
remissions, and a fluctuating course) are also common clinical features of nonfunctional tics
[90]. This may be why functional tics are rarely reported, accounting for only 2 percent of
FMD [91].
An increase in functional tics has been observed during the coronavirus disease 2019
(COVID-19) pandemic [92-94]. Cases have been referred to as "TikTok tics," as affected
individuals have commonly viewed online videos depicting tic-like behaviors. Most patients
are females between 15 and 25 years of age [92]. Symptom onset is usually acute, with
complex vocal and motor tics involving large-amplitude arm movements, self-injury, and a
wide range of odd words or phrases, often with obscenities (coprolalia). Comorbid anxiety
and depression are common.
Positive signs for functional tics include an inability to voluntarily suppress the movement,
incomplete premonitory urge, and lack of fully stereotyped movements [90]. Coprolalia,
particularly complex phrases, more commonly occurs in functional tics and is relatively rare
in nonfunctional tics. In general, it is not common for tics to begin de novo in adults, and the
presence of this alone should raise suspicion for a functional tic disorder.

COMORBIDITIES
As a functional neurologic symptom disorder, FMD is highly comorbid with psychiatric,

neurologic, and medical illnesses. Comorbidities are important to recognize as they may
contribute to symptom genesis, perpetuation, and treatment response.
Patients have high rates of depression, generalized anxiety, panic, posttraumatic stress, and
dissociative and somatoform symptom disorders. Personality disorders are also more
common than in patients with neurologic disease, especially borderline, histrionic, and
narcissistic types. (See "Conversion disorder in adults: Clinical features, assessment, and
comorbidity", section on 'Psychiatric disorders'.)
Chronic pain, fatigue, anxiety, and cognitive symptoms are common in patients with FMD
and occur at higher rates than formal psychiatric diagnoses [15,95]. Anxiety is especially
common in patients with functional tremor but may not present overtly. Coexisting
nonmotor functional symptoms, including functional seizures, sensory symptoms, visual
symptoms, bladder changes, and irritable bowel symptoms, are also common. Comorbid
movement disorders are diagnosed in approximately 15 to 25 percent of patients with FMD
[9,96].
Some patients report prior suicidal ideation or suicide attempts [38,72], self-injurious
behaviors [97], and psychiatric hospitalizations [38]. Increased harm avoidance and
impulsivity, decreased novelty-seeking, self-directedness and active problem-solving, and
external rather than internal locus of control have all been described in FMD [60-62].
Alexithymia, or difficulty recognizing emotion, has also been associated with FMD [38], but
this remains controversial.
EVALUATION AND DIAGNOSIS
FMD is diagnosed clinically based upon characteristic clinical features and demonstration of
positive signs ( table 4). FMD should be suspected in patients with movements or postures
that do not conform to usual characteristics of neurologic disorders; although psychiatric
comorbidity is common, it is not always evident at the time of presentation and is not
required for the diagnosis.
The diagnosis of FMD is best made by clinicians with expertise in movement disorders,
including general neurologists [98]. An accurate diagnosis depends not only on the ability to
recognize the characteristic features of FMD, but also on a strong knowledge of other
movement disorders and their common and rare variants.
General principles
Rule-in, not rule-out – FMD is a "rule-in" diagnosis that requires the presence of
characteristic clinical features ( table 3) and the demonstration of positive signs
( table 4) [99,100]. FMD is not a diagnosis of exclusion.
Comorbidity – Coexisting psychological factors and psychiatric disorders are not

required for a diagnosis of FMD [4]. Pain, fatigue, and cognitive symptoms are
common. FMD can coexist with other neurologic illness, including other movement
disorders.
Role of investigations – Investigations should be done as appropriate to rule out

comorbid neurologic disease. Laboratory-supported diagnoses with electrophysiology
can be used in challenging cases of functional tremor or myoclonus. (See
'Electrodiagnostic testing' below.)
Rate of misdiagnosis – Misdiagnosis is rare in patients who receive an appropriate

neurologic evaluation. A systematic review found that the misdiagnosis rate for patients
with various functional symptoms, including some with abnormal movements, has
been 4 percent since the 1970s [101]. While not specific for FMD, this finding suggests
that the misdiagnosis rate is not unacceptably high compared with other psychiatric
and neurologic disorders [102]. In some cases, FMD may be the presenting syndrome
heralding development of another neurologic disease, and patients should be
reevaluated in the setting of new or changing symptoms [103].
Diagnostic criteria (DSM-5) — The Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition (DSM-5) classifies abnormal functional movements as a subtype of functional
neurologic symptom disorder (conversion disorder) [1]. A DSM-5 diagnosis of conversion
disorder requires symptoms of altered voluntary motor or sensory function, incompatibility
with a recognized neurologic or general medical condition, lack of a better explanation, and
the presence of significant distress or psychosocial impairment ( table 1). (See "Conversion
disorder in adults: Terminology, diagnosis, and differential diagnosis", section on 'Diagnosis'.)
History — History and direct observation are the core components of the diagnostic
evaluation. Clinicians should ask about all of the following items, each of which is discussed
in more detail separately (see "Conversion disorder in adults: Clinical features, assessment,
and comorbidity", section on 'History'):
All current symptoms (neurologic, constitutional, psychological)

Circumstances at onset of symptoms (injury, illness, procedures)
Course of illness (duration, variability, triggers, alleviating factors, treatment trials,
remissions)
Disability (physical, psychosocial, occupational)
Ideas, concerns, and expectations

Psychosocial functioning
Dissociation (feeling disconnected from oneself or the environment)
Family history (neurologic disorders, psychiatric disease, functional disorders)

Previous functional symptoms and disorders
Prior clinical experiences (misdiagnosis, iatrogenesis, excess tests and medication trials;
often major source of mistrust and powerlessness)
Recent psychological stressors

Symptoms of comorbid psychiatric disorders
Examination and positive signs — Positive signs ( table 4) are essential in diagnosing

FMD [1]. Among functional neurologic symptom disorders, movement disorders are
particularly amenable to positive signs on examination that aid the clinician to rule in a
correct diagnosis. Demonstrating the positive sign to the patient is also an invaluable means
of explaining the diagnosis, and it is useful when suggesting treatment approaches (See
'Education' below.)
The hallmark positive signs in FMD are internal inconsistency and incongruence with known
patterns of abnormal movement seen in other neurologic diseases. Internal inconsistency
refers to the tendency of the symptom to change over time or depending on the context and
includes variability, distractibility, and augmentation with attention. These features apply to
almost all FMD phenotypes. Additional positive signs specific to certain phenotypes are
described above (see 'Clinical features' above) and listed in the table ( table 4).
Positive signs have shown a wide range of sensitivity (9 to 100 percent) but tighter range of
specificity (64 to 100 percent) in functional motor and sensory symptom disorders, with 37
out of 41 signs having a specificity over 90 percent [76].
Distractibility — Distracting maneuvers temporarily diminish the intensity of FMD or

suppress it entirely. By contrast, distracting maneuvers usually increase the intensity of
abnormal movements in other movement disorders (such as dyskinesia in Parkinson
disease).
Distraction techniques can be cognitive or motor and must be of sufficient difficulty to truly
distract the patient.
Cognitive distractions – Examples include the history portion of the assessment,

reciting the months of the year backward, listing animals, and generating words that
begin with the same letter.
Motor distractions – Examples include the cranial nerve examination (ocular and oral
movements are potent distractions if the functional movements do not involve the

face), finger-counting in the contralateral hand, and asking the patient to draw letters
or numbers in the air with their upper limb or on the floor with their foot. The
distracting motor task must also be used in a part of the body not involved in the
abnormal movement.
Distracting maneuvers may not be effective in longstanding FMD [104]. Fixed dystonia,
functional myoclonus, and episodic or paroxysmal FMD are also less amenable to distraction.
A corollary positive sign to distraction is when the symptom enhances when attention is
drawn to it, either when the patient is describing it during the history, when it is pointed out
by the examiner, or when the patient is engaging in a voluntary task that involves the body
part with the symptom of concern (eg, writing in a patient with a functional dominant-hand
tremor).
Variability — Variability is a core feature of FMD. Functional symptoms wax and wane over
time. Variability can refer to the natural history of a symptom over time (by history) or at
different points during the assessment. Functional movements may vary in terms of
frequency, amplitude, direction, or location in the body.
Variation with body position is common in FMD. Seated findings may not correlate with the
same findings while the patient is lying supine or walking. Findings may be different in the
waiting room versus the clinic room.
Electrodiagnostic testing — Electrodiagnostic methods can provide additional supportive

evidence for the diagnosis of functional tremor and functional myoclonus. However,
electrodiagnostic methods for analyzing tremor and myoclonus require special expertise, are
not universally available, and depend on patient effort for accuracy. They are not required or
indicated in the majority of patients.
There are no definitive electrodiagnostic tests for distinguishing functional dystonia from
other forms of dystonia [105].
Tremor analysis – Tremor analysis using surface electromyography (EMG) and

accelerometry can identify features associated with functional tremor, including
entrainment, coactivation of antagonist muscles, variability in tremor frequency, and
increased tremor amplitude and frequency with weight-loading of the involved limb
[25,47,104,106-108]. Coherence analysis is a quantitative method to determine the
similarity of tremor oscillation frequency and phase in different limbs or body parts.
Functional tremor typically has the same frequency in different limbs, and changes in
frequency are simultaneous when they occur [109]. By contrast, most other forms of
tremor, including essential tremor and parkinsonian tremor, have similar but slightly
different frequencies in different body parts, consistent with the presence of multiple
oscillators [105].
Entrainment is a property whereby a functional tremor synchronizes with the frequency

of voluntary tapping of another body part, most often the opposite hand. The degree of
similarity of tremor frequency with voluntary tapping can be assessed by coherence
analysis. Lack of entrainment suggests another etiology of tremor, since essential
tremor and parkinsonian tremor maintain their original frequencies and do not entrain.
However, in some cases functional tremor will stop or change frequency rather than
show clear entrainment. [104].
Myoclonus analysis – Electrodiagnostic techniques, including surface EMG,

electroencephalography (EEG), back-averaged EEG, and somatosensory evoked
potentials, can be helpful in differentiating functional myoclonus from true myoclonus.
Features associated with functional myoclonus on surface EMG include abnormally long
and variable latency between the stimulus and the myoclonic jerk, variable patterns of
muscle recruitment with each jerk, prolonged myoclonic burst duration, a triphasic
pattern of agonist and antagonist muscle activation, and habituation with repeated
stimulation [110,111].
In organic myoclonus of cortical origin, the myoclonic jerk has a short latency of 60 to
70 ms after a stimulus-induced cortical evoked potential on EEG and consists of short-
duration (10 to 50 ms) burst activity in an agonist muscle on EMG accompanied by co-
contraction in antagonist muscles. Brainstem myoclonus has short latencies (less than
80 ms) affecting the upper body. A pattern consistent with voluntary movement (ie, a
long latency of 100 to 120 ms from stimulus to jerk) is suggestive of functional
myoclonus. In addition, functional myoclonus is usually but not always preceded by a
Bereitschaftspotential, which is a normal movement-related cognitive potential
indicative of premotor activity that occurs prior to movement on back-averaged EEG
[112].
Neuroimaging — Neuroimaging is usually obtained to exclude the possibility of a coexisting

structural abnormality alongside FMD, such as demyelination or a compressive
radiculopathy. The decision to image and the specific study should be based on clinical
suspicion. Brain magnetic resonance imaging (MRI) is often the appropriate study, although
a spine MRI may also be indicated for certain cases of myoclonus, dystonia, or tremor when
symptoms involve a single limb. Care must be taken in explaining to patients why
investigations are being done and to prepare the patient for potentially incidental findings.
Striatal dopamine transporter imaging using 123I-FP-CIT single-photon emission computed

tomography (DaTscan) is not routinely indicated in the evaluation of FMD and is not specific
for a functional cause. In a patient with parkinsonism, a normal DaTscan would be supportive
of several diagnoses, including functional, drug-induced, or vascular parkinsonism [89]. In
addition, a change from normal to abnormal may occur over time, and, therefore, a single

test should not be used to support a diagnosis of FMD. (See "Diagnosis and differential
diagnosis of Parkinson disease", section on 'DaTscan'.)
Differential diagnosis — An accurate diagnosis of FMD depends on strong knowledge of

other movement disorders and their common and rare variants. Movement disorders that
may be confused with functional movements vary based on the particular movement and are
discussed above. (See 'Clinical features' above.)
The differential diagnosis of functional neurologic symptom disorder can also include
psychiatric disorders, including somatic symptom disorder, depersonalization/derealization
disorder, feigned symptoms, factious disorder, and malingering. The distinction between
these disorders and functional disorders is reviewed separately. (See "Conversion disorder in
adults: Terminology, diagnosis, and differential diagnosis", section on 'Differential
diagnosis'.)
TREATMENT
Treatment of FMD follows the same principles of therapy as for functional neurologic
symptom disorder. Treatment should be individualized and follow a stepped model of care
based on symptom severity and complexity to optimize resource allocation [113].
Step 1 – All patients should be provided with a diagnosis, education, and advice by a
neurologist as first-line therapy. (See 'Delivering the diagnosis' below and 'Education'
below.)
Step 2 – Patients with more severe symptoms but without complex psychiatric
comorbidities may benefit from a brief rehabilitation intervention with a physical,
occupational, or speech therapist, with or without accompanying psychotherapy. (See
'Motor retraining' below and 'Psychological therapies' below.)
Step 3 – Patients with complex symptom presentations, those with a high level of
disability and comorbidities, and those who have failed prior treatment interventions
may require specialized multidisciplinary therapy delivered in an outpatient, day
hospital, or inpatient setting [114]. (See 'Multidisciplinary therapies' below and
'Refractory/chronic disease' below.)
Delivering the diagnosis — The first line of treatment consists of disclosing the diagnosis to
the patient. Clinicians should demonstrate the rationale for the diagnosis of FMD, show the
patient their positive signs, and convey recovery potential.
It should be emphasized that the problem is not "made up" by the patient, or "in their head,"
or "put on." FMD is a real and common condition. It is important to take the patient's

complaints seriously. Some patients with FMD will have had prior negative experiences with
health care providers, and inquiring about these instances while also validating the patient's
symptom complex can help build rapport and engagement [12]. Importantly, some patients
will improve with a well-delivered diagnosis alone.
A roadmap for presenting the diagnosis is reviewed in more detail separately. (See
"Conversion disorder in adults: Treatment", section on 'Presenting the diagnosis'.)
Education — Patients should be directed to reliable sources of information about FMD.

Some neurologists find it useful to review symptoms with the patient using a website, FND
Guide, which presents balanced information about functional neurologic symptom disorders
including FMD.
Demonstration – Showing the patient their positive signs is a valuable way to help the
patient agree with and understand the diagnosis, particularly in movement disorders
[115]. For example, demonstrating to the patient that their tremor temporarily resolves
when they tap the fingers of their other hand shows them not only that distraction
improves the tremor, but also that their nervous system is capable of functioning
normally at times.
Entrainment – Entrainment can be used as a therapeutic strategy at the time of

diagnosis at the bedside to show the patient that they can retrain the tremor frequency
and reduce the tremor severity (ie, "self-entrain") [116]. This tends to be most useful for
unilateral functional hand tremor. The contralateral hand taps the leg at a fast
frequency that matches the frequency of the tremor. The patient then deliberately
slows down the frequency until it stops, and the entrained hand also stops.
Use of analogies – Explaining the diagnosis can be made easier through the use of
analogies, such as a "hardware versus software" problem, or abnormal motor programs
learned by the brain.
Role of psychiatry referral — The role of the psychiatrist ranges from diagnostic

elaboration to the provision of treatment. The reason why psychiatric referral would be
helpful should be clearly communicated to the patient (ie, to help us understand your brain
better, not for diagnostic confirmation) so they can make an informed decision if they wish to
have an evaluation.
Involving psychiatry is vital at the time of diagnosis when comorbid psychiatric diagnoses are
suspected and/or previously identified and not optimized, such as untreated anxiety or
depression, posttraumatic stress, personality traits, dissociation, or unusual symptoms such
as psychosis. Alternatively, psychiatric evaluation can identify relevant risk factors (such as
trauma) and psychosocial perpetuating factors relevant to treatment triage. In these cases,
developing a partnership between neurology and psychiatry and using a similar framework
of understanding goes a long way in reducing stigma, countering dualism, and building a
positive therapeutic relationship.
Specialized therapies
Motor retraining — For most patients who do not improve with education alone, we
suggest specialized rehabilitation, which can be delivered by physiotherapists [117],
occupational therapists [118], or speech therapists [119], depending on the movement
disorder. It is important to note that the principles of rehabilitation for FMD differ from
traditional neurorehabilitation, so in ideal cases the therapist is familiar with FMD.
Eligibility and barriers – Prior to embarking on therapy, it is important to determine if

any barriers to rehabilitation are present, such as severe pain or fatigue, diagnostic
disagreement or alternate illness beliefs, or ongoing psychosocial stressors that will
limit engagement [12].
It is also important that the symptoms of concern to the patient (and not just the
provider) are amenable to physiotherapy. For example, gait disorders or tremor that are
present more or less constantly are more amenable to rehabilitation than episodic
generalized dystonia, in which the symptoms are only intermittently present, or fixed
dystonia, in which there is little to no variability present.
Therapeutic principles – The principles of motor-retraining physiotherapy differ

markedly from standard neurorehabilitation; thus, working with a therapist with
experience in these techniques is essential. Therapy is delivered within a psychologically
informed framework, and relaxation and mindfulness training are incorporated into
treatment sessions. FMD-specific therapy principles include [117-120]:
• Address function, such as transfers and walking, rather than impairments such as
weakness
• Divert attention away from abnormal movements
• Notice symptom variability
• Use energy/activity rationing, also called pacing
• Limit "hands-on" treatment
• Facilitate rather than support movements
• Encourage early weight-bearing
• Use a goal-directed approach focused on function and automatic movement
• Minimize reinforcement of maladaptive movement patterns and postures
• Avoid adaptive equipment and mobility aids
Efficacy – There is now a good evidence base for physiotherapy for FMD, including
several small, randomized trials [117,121-123].

• A randomized trial compared three weeks of inpatient physical therapy (including

education) with a waiting list control condition in hospitalized patients with
psychogenic gait disorder (n = 60) [122]. Ambulation and functional independence
improved significantly more with physical therapy, the clinical effect was large, and
the benefits were maintained at one-year follow-up.
• A second randomized trial compared a five-day intensive outpatient specialized

physical therapy program with standard neurologic physical therapy in 60 patients
with functional motor disorders [124]. The control group received an average of five
sessions. At six-month follow-up, improvement occurred in four times as many
patients in the intervention group than the controls (72 versus 18 percent).
Psychological therapies — Psychiatric interventions are individualized according to the

underlying psychiatric diagnosis and best accomplished by involvement with a psychiatrist or
psychologist who is familiar with FMD.
Patients may decline psychotherapy because they refuse to accept that "talking" treatments
can be beneficial for physical symptoms. This concern can often be addressed by delivering
psychotherapy as part of medical care, validating the patient's experience and symptoms as
not being "all in their head," and using integrated care models with partnerships between
neurology and psychiatry [125,126]. In some cases, pharmacotherapy may be useful for
comorbid, active psychiatric concerns such as depression or anxiety [127]. (See "Conversion
disorder in adults: Treatment", section on 'Pharmacotherapy'.)
In FMD, psychotherapy can be effective either in conjunction with motor retraining or

delivered sequentially [128-131]. As an example, functional tremor with accompanying
anxiety can be treated with motor retraining physio- or occupational therapy to target
tremor, in concert with cognitive-behavioral therapy (CBT) to target unhelpful thought
patterns and anxiety. One study in 15 patients with functional tremor showed complete
remission at 12 weeks in 73 percent of the cohort following a course of CBT alone [131]. (See
"Conversion disorder in adults: Treatment", section on 'Cognitive-behavioral therapy'.)
Psychodynamic psychotherapy has a good evidence base in functional neurologic symptom

disorder. Studies in FMD are more limited, but there may be a role for individual
psychotherapy with or without pharmacotherapy [132]. (See "Conversion disorder in adults:
Treatment".)
Multidisciplinary therapies — Patients with complex symptom presentations, those with a

high level of disability and comorbidities, and those who have failed prior treatment
interventions may benefit from specialized multidisciplinary therapy delivered in an
outpatient, day hospital, or inpatient setting.

Inpatient programs for severe FMD cases have shown good clinical outcomes in
observational studies [8,133-137]. As an example, a prospective observational study assessed
patients (n = 66) who were hospitalized on a specialist unit for severe conversion disorder
(mixed subtype) and received a four-week multidisciplinary program that included physical
therapy, occupational therapy, CBT, neuropsychiatry assessment, and neurology input as
required. Improvement of psychiatric symptoms, behavior, and functioning at discharge was
significant and clinically large, according to clinician ratings [137]. General health was rated
as "better" or "much better" by 66 percent of patients, both at discharge and the one-year
follow-up assessment.
Complex patients are more resource intensive and require specialized outpatient care as
well. Such patients may benefit from dedicated functional neurologic symptom disorder
clinics where access to adjunctive treatments is available [95], such as chronic pain programs,
long-term psychotherapy, trauma therapy, and other therapies for non-movement-related
functional symptoms such as vestibular therapy.
Other therapies have been investigated in FMD and include transcranial magnetic
stimulation [138] and hypnosis [128,139]. (See "Conversion disorder in adults: Treatment",
section on 'Third line treatment'.)
Refractory/chronic disease — A large proportion of patients will not respond to treatment

and develop chronic FMD. It is important for the clinician to realize that the absence of a
structural lesion does not mean that the problem will resolve on its own. Therapy for FMD is
considered "opt-in," and many patients will not be ready to engage in treatment at a
particular time. Applying treatment to a patient who is not ready to engage will generally be
unsuccessful.
Chronic FMD occurs for several possible reasons, including internal and external factors
related to the patient and the health care team. Misdiagnosis and unrecognized
comorbidities should always be considered when patients fail to respond to standard
therapies. (See "Conversion disorder in adults: Treatment", section on 'Persistently ill
patients'.)
In patients with chronic FMD, treatment may consist of periodic reassessments to ascertain
readiness to engage in treatment, reassurance around new symptoms, and prevention of
iatrogenic harm from diagnostic tests or surgical procedures. Persistently ill patients should
generally be treated by primary care clinicians with a conservative approach, along the lines
of prophylactic management models used in somatization disorder. (See "Somatic symptom
disorder: Treatment", section on 'Treatment-refractory patients'.)
Identifying who may or may not respond to therapy upfront and triaging to appropriate
treatments are important for resource allocation, given the prevalence of these disorders

and the high health care utilization of this portion of the population.
PROGNOSIS
Prognosis for functional neurologic symptom disorder as a whole is guarded, and many
patients face long-term symptoms and disability. Across subtypes, patients with sensory
symptoms tend to do better than those with weakness/paralysis and FMD. (See "Conversion
disorder in adults: Epidemiology, pathogenesis, and prognosis", section on 'Prognosis'.)
In a systematic review of FMD that identified 24 studies in 2069 patients, 40 percent of

patients had the same or worse outcome with a median follow-up of 7.4 years, and only 20
percent of patients experienced complete remission [140]. Among phenotypes, functional
dystonia had the worst prognosis, with nearly 80 percent of patients having the same or
worse symptoms over time [140,141]. Functional tremor also has a relatively poor prognosis,
with 44 to 90 percent of patients the same or worse at follow-up [19,47,142,143]. An
important limitation is that most prognostic studies have been in untreated cohorts.
Baseline predictors of outcome in patients with FMD are similar to those in patients with
other subtypes of functional neurologic symptom disorder ( table 5). There is conflicting
evidence regarding the correlation of prognosis with pending litigation, age, comorbid
anxiety and depression, intelligence quotient, educational status, and marital status [140].
The interpretation of most prognostic studies is hampered because patients with functional
symptoms were not compared with controls with recognizable neurologic disease.
FMD often occurs in midlife, and the socioeconomic impact is notable. Patients with FMD
show comparable rates of disability to those seen in other neurologic diseases, though with
increased rates of total symptom burden and mental distress [144,145]. Unemployment rates
range from 23 to 84 percent, and the reported percentage of patients who are receiving or
seeking medical disability has ranged from 24 to 55 percent [12]. One multicenter study of
FMD from Canada, the United Kingdom, and Switzerland found that 35 percent of patients
were not working because of ill health, 26 percent were receiving disability benefits, and 10
to 38 percent required a care provider for daily activities [95].
SUMMARY AND RECOMMENDATIONS
Definition – Functional movement disorder (FMD) is a subtype of functional neurologic

symptom disorder (also known as conversion disorder) defined by abnormal
movements that occur as a result of abnormal functioning of the nervous system,
incongruent with known movement disorders. (See 'Introduction' above and
'Terminology' above.)

Epidemiology – FMD accounts for 2 to 10 percent of all movement disorders.

Functional tremor is the most frequent phenotype of FMD, followed by functional
dystonia. Mixed FMD with more than one phenotype is common. (See 'Epidemiology'
above.)
Etiology – FMD is best conceptualized using a biopsychosocial model of predisposing,

precipitating, and perpetuating factors. Factors can be biologic, psychological, or social,
and the combination of factors is unique to each patient ( table 2). (See 'Etiologic
factors' above and 'Pathogenesis' above.)
Clinical features – FMD often begins abruptly after illness or injury, has a fast
progression to disability, and is associated with variable symptoms that wax and wane
over time ( table 3). Symptoms usually improve with distraction and worsen with
attention. (See 'Shared features' above.)
The main FMD syndromes are functional tremor, functional dystonia, functional gait,
functional myoclonus, and functional parkinsonism. Each is associated with distinctive
clinical features and positive signs that help distinguish FMD from other movement
disorders ( table 4). (See 'Functional tremor' above and 'Functional dystonia' above
and 'Functional gait' above and 'Functional myoclonus' above and 'Functional
parkinsonism' above and 'Functional tics' above.)
Diagnosis – FMD is a rule-in diagnosis and not a diagnosis of exclusion, and follow-up is
required as clinically indicated. Accurate diagnosis is based on the entire clinical picture
and demonstration of positive signs on examination. Coexisting psychological factors
and psychiatric disorders are common but not required. (See 'Evaluation and diagnosis'
above.)
Laboratory-supported diagnosis can be achieved in challenging cases of tremor or

myoclonus using electrodiagnostic studies, such as electromyography (EMG) and
electroencephalography (EEG). Neuroimaging has a role when there is clinical suspicion
for a coexisting structural abnormality alongside FMD. (See 'Electrodiagnostic testing'
above and 'Neuroimaging' above.)
Treatment – Optimal management of FMD consists of early diagnosis and

individualized treatment depending on symptom severity and syndrome complexity.
There is no "one size fits all" treatment. (See 'Treatment' above.)
• Treatment begins with diagnosis delivery. Clinicians should emphasize the rationale
for the diagnosis, demonstrate to the patient their positive signs, convey the
potential for reversibility, and provide educational resources, such as FND Guide.
(See 'Delivering the diagnosis' above and 'Education' above.)

• Patients who do not improve with diagnosis and education alone are offered motor
retraining physiotherapy, occupational therapy, or speech therapy. (See 'Motor
retraining' above.)
• Psychological therapies such as cognitive behavioral therapy can be effective

adjuncts to physical therapy, either together or in sequence. (See 'Psychological
therapies' above.)
• Multidisciplinary rehabilitation in either in- or outpatient models may be required for

more complex, longstanding, and/or highly disabled patients. (See 'Multidisciplinary
therapies' above.)
• Some patients will not improve with therapy. Management of chronic FMD should
center around minimization of iatrogenic harm. (See 'Refractory/chronic disease'
above.)
Prognosis – Prognosis for FMD is generally unfavorable in untreated cohorts. Factors

associated with a more favorable prognosis include short duration of symptoms, early
diagnosis, and good therapeutic alliance with the clinician ( table 5). (See 'Prognosis'
above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Janis M Miyasaki, MD, MEd, who contributed to an
earlier version of this topic review.
Use of UpToDate is subject to the Terms of Use.
Topic 14132 Version 31.0

GRAPHICS
DSM-5 diagnostic criteria for conversion disorder
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized
neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or warrants medical evaluation.
Specify symptom type:
With weakness or paralysis
With abnormal movement (eg, tremor, dystonic movement, myoclonus, gait disorder)
With swallowing symptoms
With speech symptoms (eg, dysphonia, slurred speech)
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptoms (eg, visual, olfactory, or hearing disturbance)
With mixed symptoms
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright ©
2013). American Psychiatric Association. All Rights Reserved.
Graphic 91102 Version 6.0

Potential etiologic factors in patients with functional symptoms
Factors Biologic Psychological Social
Acting at all Recognized Emotional disorder Socioeconomic/deprivation

stages neurologic/medical Personality Life events and difficulties
disease disorder
Previous functional
symptoms or
disorders
Predisposing Genetic factors Perception of Childhood neglect/abuse

affecting childhood
personality experience as
Biologic adverse
vulnerabilities in Personality traits
the nervous Poor
system? attachment/coping
style
Precipitating Abnormal Perception of life

physiologic event event as negative,
or state (eg, unexpected
hyperventilation, Acute dissociative
sleep deprivation, episode/panic
sleep paralysis) attack
Physical
injury/pain
Perpetuating Plasticity in CNS Perception of Stigma against functional

motor and sensory symptoms as disorders in society and
(including pain) unamenable to from clinicians
pathways rehabilitation Clinician failure to make or
Deconditioning therapy communicate a diagnosis
Neuroendocrine Not being believed when present
and immunologic Avoidance of Iatrogenic harm (eg,
abnormalities symptom surgery, opiates, or other
similar to those provocation medication)
seen in depression Fear of falling or Legal compensation cases
and anxiety seizures
CNS: central nervous system.
Adapted with permission from: Stone J. The bare essentials: Functional symptoms in neurology. Pract Neurol 2009; 9:179.
BMJ Publishing Group Ltd. Copyright © 2009.

Clinical characteristics of functional movement disorders
Abrupt onset
History of a precipitating event, usually physical injury or illness
Fast progression to maximum symptom severity and disability
Movement abnormality that is incongruent with known disease
Variability in movement characteristics (eg, amplitude, frequency, or distribution)
Variability in the movement symptom over time (eg, during history, examination, waiting room)
Waxing and waning symptoms over time (ie, "good and bad" days)
Normalized movement disorder with distraction
Worsened movement disorder with attention (eg, during observation or examination)
Entrainment of movement (eg, tremor) to the frequency of repetitive movements
Presence of comorbid pain, fatigue, and cognitive symptoms
Presence of comorbid neurologic disease
Functional disability out of proportion to examination findings

Examples of functional cranial dystonia
The most common phenotype, isolated lower lip dystonia (A, B), in a patient with spontaneous
remissions and intermittent ipsilateral jaw deviation; eyelid spasm may be ipsilateral (C) or contralateral
to the lip pulling (D). Note that the contraction of frontalis muscle involves the eyebrow contralateral to
the spasm of the orbicularis oculi (arrows indicate a false "other Babinski sign"); platysma involvement is
always associated with ipsilateral lip involvement (E), which can rapidly fluctuate in severity and
appearance (F, G, same case). Some patients demonstrate severe bilateral spasms of most facial
musculature (H), which may remit after placebo (vibrating tuning fork application, I) and relapse with
different phenomenology shortly thereafter (J).
From: Fasano A, Valadas A, Bhatia KP, et al. Psychogenic facial movement disorders: Clinical features and associated conditions.
Mov Disord 2012; 27:1544. https://movementdisorders.onlinelibrary.wiley.com/doi/10.1002/mds.25190. Copyright © 2012 John

Wiley & Sons Ltd. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley.
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permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request
Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/).

Positive signs in functional movement disorders
Functional
movement Positive sign Description
symptom
Can be present in all Variability Generally refers to changing patterns over

functional movement time, including susceptibility to distraction
symptoms and enhancement with attention
Distractibility Movement normalizes during a cognitive or

motor task
Enhancement with Movement worsens/emerges when attention

attention is drawn to it
Motor inconsistency Movements are preserved in some

circumstances and impaired in others (eg,
dorsiflexion weakness during power testing,
and able to stand or put on shoes when not
examined)
Incongruency A clinical picture incompatible with known

organically determined patterns
Suggestibility Movement is elicited with verbal instruction or

by a maneuver from the examiner (eg, tuning
fork test)
Weakness Hoover sign Weakness of hip extension in a paretic leg

that resolves with contralateral hip flexion
against resistance in the normal leg
Hip abductor sign Weakness of hip abduction in a paretic leg

that resolves with contralateral hip abduction
against resistance in the normal leg
Finger abduction sign Weakness of finger abduction that resolves

with contralateral finger abduction against
resistance
Give-way/collapsing Limb collapses from a normal position with a

weakness light touch, or normal strength is developed
and then suddenly collapses
Absent pronator drift Extended supinated arm drifts down without

pronation
Co-contraction Simultaneous contraction of agonist and

antagonist resulting in no/little movement
Tremor Variability Changes in tremor characteristics (usually

frequency and/or direction) over time and
with position
Entrainment Tremor takes up the same frequency of an

externally cued rhythmic movement (either

patient or examiner)
Co-contraction Simultaneous contraction of agonist and

antagonist resulting in tremor
Whack-a-mole sign Emergence or worsening of an involuntary

movement in a separate body part when the
initially affected body part is suppressed by
examiner restraint
Myoclonus/jerks Variability Duration, distribution, and/or latency (if

stimulus sensitive) of jerks variable
Entrainment Jerks take up the same frequency of an

externally cued rhythmic movement (either
patient or examiner)
Axial/facial jerks Axial or facial jerks predominate
Gait/balance disorder Gait variability Inconsistent deficits in gait and stance with
normal periods of walking observed
Monoplegic leg- The leg is dragged at the hip behind the body
dragging gait instead of performing a circumduction
Excessive slowness Excessive slowness or hesitation incompatible

with a neurologic disease
"Walking on ice" gait A walking pattern mimicking ice skating or as

if on slippery ground
Functional Romberg Constant falls towards or away from the

observer, large-amplitude body sway building
up after a latency of a few seconds, and
improvement of balance with distraction
Uneconomical A walking pattern that requires considerable

postures effort as well as balance to maintain the
posture (eg, crouching, dragging)
Knee-buckling The knees give way but without full collapse
Swivel chair sign Preserved ability to propel a swivel chair while

seated
Facial symptoms Functional facial Tonic pulling of the lips (or jaw) to one side
spasms with or without contralateral frontalis
activation; usually ipsilateral platysma
overactivation
Functional Closed eyelids resist retraction

blepharospasm
Fixed dystonia Hand posture Flexed digits 3 to 5 with preserved pincer

function
Foot posture Inversion and plantar flexion in the foot and

ankle

Cervical posture Laterocollis, ipsilateral shoulder elevation, and

contralateral shoulder depression
Slowness/parkinsonism Excessive slowness Excessive slowness or hesitation incompatible

with a neurologic disease
Hypokinesia without Continuously slow movements on repetitive

decrement testing without true decrement of speed or
amplitude seen in bradykinesia
Paratonia/Gegenhalten Variable resistance during passive

manipulation of a joint
"Huffing and puffing" Simple movements appear effortful

sign
Tics Functional tics Not fully stereotyped, interfere with speech or

voluntary actions, lack of clear premonitory
urge, and inability to voluntarily suppress
Adapted from: Lidstone SC, Nassif W, Juncos J, et al. Diagnosing functional neurological disorder: Seeing the whole
picture. CNS Spectr 2021; 26:593.

Prognostic factors in functional neurological symptom disorder

(conversion disorder)
Positive prognostic factors Negative prognostic factors
Onset in childhood or adolescence Multiple physical symptoms
Early diagnosis Longer duration of symptoms
Good response to initial treatment Poor physical functioning
Comorbid anxiety or depression Comorbid personality disorder
Subsequent change in marital status Beliefs that symptoms are irreversible and
caused by a disease with a known
pathologic basis
Good therapeutic alliance with the clinician Illness-related financial benefits


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10/26/22, 11:11 AM Functional movement disorders - UpToDate

Official reprint from UpToDate®

Functional movement disorder (FMD) is a subtype of functional neurologic symptom disorder

(See "Conversion disorder in adults: Epidemiology, pathogenesis, and prognosis".)

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 1/35

FMD is a subtype of functional neurologic symptom disorder (conversion disorder)

Subtypes of functional neurologic symptom disorder recognized by DSM-5 include (from

Prevalence in clinical settings – FMD accounts for 2 to 10 percent of patients in

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 2/35

Phenotype frequency – Functional tremor is the most frequent FMD phenotype,

Predisposing factors – Common risk factors for developing FMD include:

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 3/35

single-nucleotide polymorphisms from 14 candidate genes among patients with FMD

Precipitating factors – A precipitating factor occurring in close temporal proximity with

• Physical injury or accident

Cognitive-behavioral, neurobiologic, and psychodynamic hypotheses that attempt to explain

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 4/35

FMD is a complex neuropsychiatric condition, and underlying mechanisms are an intense

Abnormal self-directed attention

Shared features — FMD very often begins abruptly, regardless of phenotype ( table 3)

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 5/35

Once FMD is established, abnormal movements can be present constantly or occur as

Distractibility – Distractibility refers to complete remission or temporary suspension of

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 6/35

Variability – Variability manifests as changes in tremor distribution, direction,

Entrainment – Entrainment refers to a shift of tremor frequency to match an externally

Co-contraction – Patients with functional tremor may have isometric contraction of

"Whack-a-mole" sign – Movement suppression of one body part (eg, holding an

Electrophysiologic studies may be helpful in distinguishing functional tremor in challenging

Functional dystonia — Functional dystonia is the second most common type of FMD.

Functional cranial dystonias – Functional facial spasms are a common subtype of

movements or self-biting, lingual movements without mouth movements, and the

Paroxysmal mixed dystonia – The most common form of generalized functional

Functional gait — Functional gait disorders can occur as an isolated FMD or in combination

Numerous functional gait patterns have been described, including [31,70-73]:

Excessive slowness and stiffness

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~150… 9/35

Functional myoclonus — Myoclonus is a brief, shock-like muscle contraction (positive

Functional myoclonus may be underrecognized in patients presenting with sudden body

Inconsistent character of the movements (amplitude, frequency, and/or distribution)

Electrodiagnostic testing can be helpful in differentiating functional myoclonus from other

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~15… 10/35

Functional parkinsonism — The cardinal motor manifestations of parkinsonism are rest

Tremor – The tremor of functional parkinsonism shares the characteristics of isolated

Rigidity – A functional increase in muscle tone is the result of gegenhalten/paratonia

Knowledge of atypical parkinsonian disorders is also crucial in some cases to avoid

syndrome without tremor may be erroneously diagnosed with functional parkinsonism. In

A normal dopamine transporter imaging study using single-photon emission computed

Functional tics — Tics are recurrent, semivoluntary, stereotyped movements that can be

https://www.uptodate.com/contents/functional-movement-disorders/print?search=functional neurological disorder&source=search_result&selectedTitle=1~15… 12/35

As a functional neurologic symptom disorder, FMD is highly comorbid with psychiatric,

EVALUATION AND DIAGNOSIS

Comorbidity – Coexisting psychological factors and psychiatric disorders are not

Role of investigations – Investigations should be done as appropriate to rule out

Rate of misdiagnosis – Misdiagnosis is rare in patients who receive an appropriate

Diagnostic criteria (DSM-5) — The Diagnostic and Statistical Manual of Mental Disorders,

All current symptoms (neurologic, constitutional, psychological)

Ideas, concerns, and expectations

Family history (neurologic disorders, psychiatric disease, functional disorders)

Recent psychological stressors

Examination and positive signs — Positive signs ( table 4) are essential in diagnosing

Distractibility — Distracting maneuvers temporarily diminish the intensity of FMD or