Management and diagnosis of psychogenic cough, habit cough, and tic cough: a systematic review.

BACKGROUND: Several pharmacologic and nonpharmacologic therapeutic options have been used to treat cough that is not associated with a pulmonary or extrapulmonary etiology. METHODS: We conducted a systematic review to summarize the evidence supporting different cough management options in adults and children with psychogenic, tic, and habit cough. Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched from the earliest inception of each database to September 2013. Content experts were contacted, and we searched bibliographies of included studies to identify additional references. RESULTS: A total of 18 uncontrolled studies were identified, enrolling 223 patients (46% male subjects, 96% children and adolescents). Psychogenic cough was the most common descriptive term used (90% of the studies). Most of the patients (95%) had no cough during sleep; barking or honking quality of cough was described in only eight studies. Hypnosis (three studies), suggestion therapy (four studies), and counseling and reassurance (seven studies) were the most commonly used interventions. Hypnosis was effective in resolving cough in 78% of the patients and improving it in another 5%. Suggestion therapy resolved cough successfully in 96% of the patients. The greatest majority of improvements noted with these forms of therapy occurred in the pediatric age group. The quality of evidence is low due to the lack of control groups, the retrospective nature of all the studies, heterogeneity of definitions and diagnostic criteria, and the high likelihood of reporting bias. CONCLUSIONS: Only low-quality evidence exists to support a particular strategy to define and treat psychogenic, habit, and tic cough. Patient values, preferences, and availability of potential therapies should guide treatment choice.

Attentional modulation of reflex cough.

OBJECTIVE: Reflex cough is a defensive response generated in the brainstem in response to chemical and mechanical stimulation of the airways. However, converging evidence shows that reflex cough is also influenced by central neural control processes. In this study, we investigate whether reflex cough can be modulated by attentional focus on either external stimuli or internal cough-related stimuli. METHODS: Healthy volunteers (N = 24; seven men; age range, 18-25 years) completed four blocks of citric acid-induced cough challenges while, simultaneously, auditory stimuli were presented. Within each block, four concentrations were administered (30, 100, 300 and 1,000 mM, randomized). During two subsequent blocks, participants focused their attention externally (counting tones). During the other two blocks, participants focused their attention internally (counting coughs). The order of attentional focus was counterbalanced across participants. Ratings of the urge to cough were collected after each challenge. Cough frequency was determined by audio recording. RESULTS: Cough frequency was higher when participants focused their attention internally vs externally (P < .05). Also urge to cough was greater during internal vs external focus (P < .05), but the effect was smaller in later blocks of trials. CONCLUSIONS: Reflex cough can be modulated by attentional focus. Internally focused attention may be a mechanism involved in excessive (idiopathic) cough, while an external focus may be introduced as part of treatments targeting excessive cough.

The habit cough syndrome and its variations.

Involuntary cough without an identified underlying organic reason has been given various names and recommended treatments. Current experience suggests that "habit cough" best describes this entity. Suggestion therapy in its various forms is the treatment of choice. Successful therapy is directed at demonstrating to the patient that he/she has the ability to resist the urge to cough. Attempts at medical treatment or use of placebo therapy, even with the suggestion that the "medicine" will stop the cough, are generally not successful. Continued symptoms for years can occur in the absence of suggestion therapy. Sustained relapse after suggestion therapy is uncommon.

Social suffering and anxiety: deciphering coughs and colds at Akan anti-witchcraft shrines in Paris.

In treating illness and suffering, the Akan anti-witchcraft shrine is often presented as a model of unchanging, tightly bounded and antiquated ideals. This fails to acknowledge the extensive repertoire of Ghanaian witchcraft discourses and contemporary divinatory practices uncovered at Akan anti-witchcraft shrines. This paper analyses how one of the most popular Akan anti-witchcraft shrine in Europe, in an eastern banlieue of Paris, diagnoses the seemingly common and innocuous coughs and colds suffered by recently arrived, unskilled female Ghanaian migrants as something more socially and economically malignant, witchcraft. Successful treatment combines divinatory techniques, paracetamol medicines and positive thinking in order to empower clients and present them with the possibility of new social and gainful employment prospects.

[Somatoform disorder or neurological syndrome? Complex mental and movement disorder and autonomic dysfunction in a 65-year-old patient - Case 1/2011]. / Somatoforme Störung oder neurologisches Syndrom? Komplexe psychische, vegetative und motorische Störungen bei einer 65-jährigen Patientin - Fall 1/2011.

HISTORY AND ADMISSION FINDINGS: A 65-year-old female patient presented with increasing vertigo, tendency to fall, dry cough and, in addition, numerous psychic and somatic symptoms since 6 years. Former diagnostic attempts did not yield clarifying results. In part, the patient had not followed up on former recommendations for further diagnostic procedures. With a suspected somatization disorder the patient was admitted to the Department of Psychosomatic Medicine. INVESTIGATIONS: The neurological examination at admission revealed vertical oculomotor palsy and tendency to fall backwards indicating an affection of the brain stem. A magnetic resonance imaging of the head showed atrophy of the mesencephalon. DIAGNOSIS AND TREATMENT: In light of these findings the patient was diagnosed Steele-Richardson-Olszewksi syndrome. The therapy which comprises training measures and medication with a cholinesterase inhibitor aims to retain neuropsychological and motional abilities. Besides, psychotherapy is offered alongside to help the patient to cope with the disease. CONCLUSIONS: Treating patients with somatic and psychological symptoms calls for careful anamnestic exploration and clinical examination. Psychological alterations following neurological affection of the brain can imitate somatization disorder.

Rural and urban Vietnamese mothers utilization of healthcare resources for children under 6 years with pneumonia and associated symptoms.

Worldwide, pneumonia causes 14% of deaths among children and infants (ages 4 weeks to 5 years). UNICEF and WHO have established treatment guidelines to reduce risk of death from pneumonia including caregiver symptom recognition, appropriate care, and use of antibiotics. In June 2008, cross-sectional survey data were collected in Khanh Hoa Province Viet Nam with 329 mothers of children under 6 years. In relation to pneumonia and associated symptoms (fever >38 °C, strong cough, "fast or difficult" breathing), data were collected on perceptions of symptom severity and child vulnerability, reported healthcare utilization including use of antibiotics, sources of health information, and barriers to care. Pearson's chi square, independent t tests, and multinomial analysis were conducted to assess different patterns of reported healthcare utilization in relation to residency (rural/urban), mother's education, and household income. Outcomes include rural and urban residency-based patterns related to perceptions of child's vulnerability and symptom severity, health facility utilization and barriers to care, and reported use of antibiotics during previous episodes of pneumonia. Implications include the need to target different healthcare facilities in urban and rural Viet Nam in relation to education about symptoms of childhood pneumonia and associated treatments.

The effect of mindfulness meditation on cough reflex sensitivity.

BACKGROUND: Chronic cough is common, and medical treatment can be ineffective. Mindfulness is a psychological intervention that aims to teach moment-to-moment non-judgemental awareness of thoughts, feelings and sensations. METHOD: 30 healthy subjects and 30 patients with chronic cough were studied in two sequential trials. For both studies, cough reflex sensitivity to citric acid (C5) was measured on two occasions, with urge to cough rated following each inhalation; between challenges subjects were randomised to (1) no intervention, (2) mindfulness or (3) no intervention but modified cough challenge (subjects suppress coughing). For the healthy volunteers, measures were 1 h apart and mindfulness was practised for 15 min. For the patients with chronic cough measures were 1 week apart and mindfulness was practised daily for 30 min. RESULTS: In healthy volunteers, median change (interquartile range (IQR)) in cough reflex sensitivity (logC5) for no intervention, mindfulness and suppression was +1.0 (0.0 to +1.3), +2.0 (+1.0 to +3.0) and +3.0 (+2.8 to +3.0) doubling concentrations (p = 0.003); there were significant reductions for both mindfulness (p = 0.043) and suppression (p = 0.002) over no intervention. In patients with cough, median change (IQR) in logC5 for no intervention, mindfulness training and voluntary suppression was 0.0 (-1.0 to +1.0), +1.0 (-0.3 to +1.0) and +1.0 (+1.0 to +2.0) doubling concentrations (p = 0.046); there was a significant reduction for suppression (p = 0.02) but not mindfulness (p = 0.35). Urge to cough did not change after mindfulness compared with control in either healthy subjects (p = 0.33) or those with chronic cough (p = 0.47). CONCLUSION: Compared with control, mindfulness decreased cough reflex sensitivity in healthy volunteers, but did not alter cough threshold in patients with chronic cough. Both groups were able to suppress cough responses to citric acid inhalation.

Workshop--cough: exercise, speech and music.

Twelve distinguished scientists attended the workshop, heard three presentations, and took part in the discussions. Fontana first described his unpublished studies on cough in exercise and during hyperventilation with healthy subjects. Both activities depressed cough induced by inhalation of distilled water aerosol (fog). The possible mechanisms were discussed. Gibson then described the successful use of speech therapy to treat chronic cough, and discussed the possible mechanisms, centering on the role of the larynx and its neural control. A comparison was made with the ability of speech and laughter to precipitate cough. Widdicombe discussed the scanty literature on the effect of singing and playing wind instruments on cough, most of the evidence being anecdotal. In the discussion periods several matters for future study arose. It is usually not clear if the modulation of cough, its depression, enhancement or excitation, arose primarily at peripheral sites (reflexes from the airways), or at a cortical level, or both. Nor is it clear whether the same results would be obtained with provoked cough and with spontaneous cough. But all three aspects of 'behavioual' changes in cough sensitivity (exercise, speech and music) could be further explored, and current techniques should make this possible.

Perceptions and beliefs about cough and tuberculosis and implications for TB control in rural Rwanda.

SETTING: Two southern provinces of Rwanda, Butare and Gikongoro. OBJECTIVES: To identify beliefs and popular perceptions on cough and tuberculosis (TB) in rural Rwanda and determine how they shape health-seeking behaviour. METHODS: Eight focus group discussions, 21 key informant interviews and 12 illness narratives were conducted between May and June 2004. STUDY POPULATION: TB patients, community members, traditional healers and health workers. RESULTS: There is wide use of herbal treatment for chronic cough in Rwanda. Patients seek conventional care when alternative treatment options fail or when severe symptoms such as shortness of breath, bloody sputum and weight loss appear. There are several local illnesses associated with chronic cough, with different alternative treatments. TB symptoms are often mistaken for the acquired immune-deficiency syndrome (AIDS). Identified causes for cough-related illnesses can be classified as biomedical (germs, internal body dysfunction and worms), environmental (seasonal changes and dust), cultural (inheritance), socio-economic (hard work, malnutrition and tobacco), and supernatural (witchcraft). Three health-seeking end points emerge for chronic cough: home care, health facility and the traditional healer. Healers in some areas, however, believe TB due to witchcraft can only be treated traditionally. CONCLUSION: This study unveils beliefs and treatment options for chronic cough in Rwanda, with important implications for TB control that should be addressed.

Review series: chronic cough: behaviour modification therapies for chronic cough.

Chronic cough (CC) can be refractory to medical treatment and newer strategies are required for these patients. Behaviour modification therapies are a potential approach for management of cough that does not respond to medical management. Behaviour modification therapy for CC involves an individually tailored programme teaching individuals to increase control over cough symptoms and includes education, specific strategies to suppress the cough, vocal hygiene training and psychoeducational counselling. Several case series have described speech pathology treatment for CC and a recent randomized control trial has demonstrated a significant improvement in symptoms. Possible mechanisms for this improvement include reduced cough reflex sensitivity, increased voluntary control of the cough and reduced stimulation of cough receptors. Respiratory retraining used by physiotherapists may also have potential for use in CC. The validity of psychological therapeutic approaches to CC rests on concepts of CC as a disorder with a psychogenic component, and the ability of cognitive therapies to modify the cough pathway. This work outlines current literature into behavioural management of CC and suggests new directions for practice and research in adults with this condition.

Biofeedback and cognitive coping in the treatment of pediatric habit cough.

Habit cough is a persistent "barking" cough that does not have a medical basis. The current study evaluated a biofeedback approach using skin temperature feedback with a family focus in the treatment of an 11-year-old girl diagnosed with habit cough. Treatment consisted of six, one hour sessions with the family for part of the session and then individually with the girl. Individual treatment involved skin-temperature biofeedback to teach relaxation during the coughing episodes. The girl was cough free at the end of the sixth session and remained cough free at the end of a one and two year follow-ups. The use of a single case baseline design demonstrated the reduction of coughing and increase in extracurricular activity. It is, noteworthy that the girl demonstrated a significant ability to increase skin temperature during treatment and when asked to try to control her cough.

Childhood habit cough treated with self-hypnosis.

OBJECTIVES: To better understand factors associated with the development and persistence of habit cough and to report use of self-hypnosis for this condition. STUDY DESIGN: A retrospective chart review was performed for 56 children and adolescents with habit cough. Interested patients were instructed in self-hypnosis for relaxation and to help ignore the cough-triggering sensation. RESULTS: The patients' mean age was 10.7 years. The cough was triggered by upper respiratory infections in 59%, asthma in 13%, exercise in 5%, and eating in 4%. Onset of the cough occurred as early as 2 years, and its average duration was 13 months (range, 2 weeks to 7 years). There was a high incidence of abdominal pain and irritable bowel syndrome in the 50% of the patients who missed more than 1 week of school because of their cough. Among the 51 patients who used hypnosis, the cough resolved during or immediately after the initial hypnosis instruction session in 78% and within 1 month in an additional 12%. CONCLUSIONS: Habit cough is triggered by various physiologic conditions, related frequently to other diagnoses, and it is associated with significant school absence. Self-hypnosis offers a safe efficient treatment.

Hypnosis in pediatrics: applications at a pediatric pulmonary center.

BACKGROUND: This report describes the utility of hypnosis for patients who presented to a Pediatric Pulmonary Center over a 30 month period. METHODS: Hypnotherapy was offered to 303 patients from May 1, 1998 - October 31, 2000. Patients offered hypnotherapy included those thought to have pulmonary symptoms due to psychological issues, discomfort due to medications, or fear of procedures. Improvement in symptoms following hypnosis was observed by the pulmonologist for most patients with habit cough and conversion reaction. Improvement of other conditions for which hypnosis was used was gauged based on patients' subjective evaluations. RESULTS: Hypnotherapy was associated with improvement in 80% of patients with persistent asthma, chest pain/pressure, habit cough, hyperventilation, shortness of breath, sighing, and vocal cord dysfunction. When improvement was reported, in some cases symptoms resolved immediately after hypnotherapy was first employed. For the others improvement was achieved after hypnosis was used for a few weeks. No patients' symptoms worsened and no new symptoms emerged following hypnotherapy. CONCLUSIONS: Patients described in this report were unlikely to have achieved rapid improvement in their symptoms without the use of hypnotherapy. Therefore, hypnotherapy can be an important complementary therapy for patients in a pediatric practice.

Case formulation and behavioral treatment of chronic cough.

The present report describes the case formulation and successful treatment of a 13 year-old boy with a severe habitual cough persisting 2 months after hospitalization, despite negative physical findings. At initial assessment, he literally coughed at every breath and was on housebound instruction. The case formulation highlighted the etiological importance of classical conditioning to breathing in air and the subsequent development of a nervous habit. Treatment was conducted over six sessions and initially involved desensitization to increasing amounts of air flow. A second phase involved strengthening awareness and control over coughing at home using self-management and positive practice procedures. The case formulation, treatment procedures and changes in coughing behavior (2-year follow-up) are described.

Responding to cough: Boholano illness classification and resort to care in response to childhood ARI.

A qualitative study into the health seeking behaviour of caretakers in response to ARI in children under five years of age was conducted in the province of Bohol, the Philippines. The study was designed to compliment survey data generated from a long running ARI intervention project, specifically to explain behaviours identified as problematic by the project. Results indicate the importance of folk diagnosis as a basis for selection of first resort for care in the management of childhood ARI. A cultural category, piang, was identified as a major factor influencing health seeking behaviour and delay in consulting the biomedical system where serious ARI exists. In addition, caretakers' financial situation and social contacts are important in their decision to seek biomedical assistance and are often implicated in delay in presentation and acting upon referral to hospital.

Psychogenic cough treated with biofeedback and psychotherapy. A review and case report.

Psychogenic cough is a barking or honking cough, which is persistent and disruptive to normal activity. The cough may be a debilitating condition that interferes with work and social relationships. Although the frequency of this condition is low, it is not rare. The majority of cases reported involve pediatric or adolescent patients. Surprisingly, there are scant data describing this condition in the adult population and no reports of biofeedback being used to treat this syndrome. We present a case report of an adult patient with psychogenic cough and review the available pediatric and adult literature. A 41-yr-old obese female presented with a complex 7-yr history of intractable, nonproductive, chronic cough. She had been avoiding social activities because of embarrassment by her repeated episodes of coughing. Extensive diagnostic work-up failed to find an organic etiology. Numerous medical and surgical treatments had failed. The patient was treated with a combination of biofeedback-assisted relaxation training, psychotherapy, and physical therapy. Review of the literature revealed only one report on adults, in which three of four patients were successfully treated with a combination of speech therapy, relaxation techniques, breathing exercises, and psychotherapy. Our success suggests a possible future use of this treatment protocol for cases of psychogenic cough.

Outcome of habit cough in children treated with a brief session of suggestion therapy.

Nine patients with habit cough, initially misdiagnosed as asthma, were treated during a period of sustained repetitive symptoms with a brief session of suggestion therapy. Symptoms had previously been present for up to 2 years (median = 2 months). Five had been hospitalized for the cough. Evaluation revealed no physiologic or radiologic abnormality. All patients became symptom free during a 15-minute session of suggestion therapy. During the subsequent week, one remained completely asymptomatic and 8 had transient minor relapses that were readily self-controlled. Seven of the 9 could be contacted for determination of long-term outcome at periods up to 9 years (median 2.2 years) after the session. Six were totally asymptomatic; one had occasional minor self-controlled symptoms. A standardized questionnaire assessing psychologic symptoms at the time of follow-up revealed no somatization nor emotional distress. In contrast to this apparent cure, others have reported extended periods of continued symptoms in the absence of a uniform treatment plan for suggestion therapy even though the correct diagnosis was made. We conclude that the classical habit cough syndrome is amenable to immediate relief and long-term cure in most cases with a single session of appropriate suggestion therapy.

Behavioral management of psychogenic cough: alternative to the "bedsheet" and other aversive techniques.

The treatment of persistent psychogenic cough, a potentially debilitating condition among pediatric patients, can pose diagnostic and treatment dilemmas. Its treatment by the use of a procedure called reinforced suggestion technique was described previously. The use of an alternative procedure relying upon parental and self-monitoring of coughing and either social or material rewards for decreasing rates of coughing is presented.

Psychogenic habit cough: review and case reports.

Psychogenic habit cough--a condition that can be debilitating if it extends over a period of years--has been described in both pediatric and adolescent populations, but not in adults. The authors review the cases of 4 adult patients with this condition, review the available pediatric/adolescent literature, and make suggestions for the direction of future research. In some cases, psychogenic habit cough in adults can be successfully treated with a combination of psychotherapy, relaxation therapy, and speech therapy.