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Advanced Neurology POTS with tics versus tic-like behaviors

Table 2. ESSTS criteria supporting the diagnosis of functional tic‑like behaviors in patients (n=4) with POTS
ESSTS criteria Case 1 Case 2 Case 3 Case 4 Total
cases
Major criterion 1 (age of onset≥12) Yes Yes Yes Yes 4/4
Major criterion 2 (rapid evolution of symptoms) Yes Yes Yes Yes 4/4
Major criterion 3a (multiple types of tic-like behaviors, with a higher frequency of complex tics than Yes Yes Yes Yes 4/4
simple ones)
Major criterion 3b (inconsistent tics that are not repetitive or stereotyped) Yes Yes Yes Yes 4/4
Major criterion 3c (complex motor tic-like behaviors including context-dependent or violent/offensive tics) No No Yes Yes 2/4
Major criterion 3d (evolution of tics not following the rostrocaudal progression) Yes Yes Yes Yes 4/4
Major criterion 3e (coprolalia) Yes No Yes No 2/4
Major criterion 3f (tics likely to be influenced by popular culture or social interactions) No No No No 0/4
Major criterion 3g (frequent fluctuations in intensity and frequency throughout the day) No Yes Yes Yes 3/4
Major criterion 3h (new tics emerging regularly) Yes Yes Yes Yes 4/4
Minor criterion 1 (comorbidity with anxiety/depression) Yes Yes Yes No 3/4
Minor criterion 2 (presence of other functional neurological symptoms) No Yes No Yes 2/4
Total criteria Major 1 Major 1 Major 1 Major 1
Major 2 Major 2 Major 2 Major 2
Major 3 Major 3 Major 3 Major 3
Minor 1 Minor 1 Minor 1 Minor 2
Minor 2
Abbreviations: ESSTS: European Society for the Study of Tourette Syndrome; POTS: Postural orthostatic tachycardia syndrome.
and a relapse in her longstanding eating disorder, which hair pulling, flailing movements, forced touching (hot
resulted in her dropping out of school. In addition to surfaces), and situation-specific rude gestures. She also
multiple motor tics mainly affecting her face and neck (eye reported a few simple motor manifestations, including
rolling, head jerks), she developed limb shaking, shouting, mouth pulling and neck tensing. In terms of her complex
and complex vocalizations. She also reported occasional vocalizations, she reported coprolalia and echolalia, as
“tic attacks” and over time her functional tics became more well as random words in the form of non-obscene socially
episodic in nature, merging into non-epileptic attacks, inappropriate utterances. In addition to her diagnoses
described as prolonged (up to 20 min) episodes of stiffening of POTS and Ehlers-Danlos syndrome, she reported
and uncontrolled movements, often accompanied by longstanding mental health issues, with previous diagnoses
unresponsiveness with preserved awareness. She reported of high-functioning ASD, anxiety, depression, eating
a 2-year history of repetitive movements and vocalizations, disorder, and borderline personality disorder. There was
in the context of her complex mental health issues. Her other no history of neurodevelopmental motor or vocal tics. She
diagnoses included POTS, high functioning ASD, anxiety received intensive input from the psychotherapy services,
and insomnia. There was no history of neurodevelopmental as well as complex pharmacotherapy for her disabling
motor or vocal tics. Her local psychiatry team prescribed symptoms. In terms of family history, she reported that
multiple pharmacological agents alongside regular therapy one of her cousins had mild tics. She attended her specialist
sessions. In her family, there were no confirmed cases consultation using a wheelchair. Her multiple repetitive
of GTS or other tic disorders. During her consultation, movements mainly affected her face and her limbs. Her
there was evidence of intermittent and distractible jerking complex motor and vocal manifestations were noted to be
movements, mainly affecting her face and her limbs. highly intermittent and distractible.

3.4. Case 3 3.5. Case 4
A 22-year-old female reported a 3-year history of repetitive A 24-year-old female came to our attention with an eight-
movements and vocalizations, with an acute onset of month history of highly variable and intermittent tic-like
complex and severe manifestations mainly involving her behaviors, characterized by uncontrolled movements
upper limbs. Specifically, she described throwing, knocking, and vocalizations, including occasional random words.
dropping objects, hitting, punching (objects, others, self), Her symptoms had an acute onset following stressful

Volume 4 Issue 2 (2025) 105 doi: 10.36922/an.8525