- Psychogenic cough
- Habit cough
- Vocal tics
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4629926/
A loud, honking cough absent during sleep is highly suggestive of a psychogenic cough, habit cough, or cough tic.
WHAT IS A HABIT COUGH
Habit cough, which has been denoted by various terms, such as psychogenic cough and cough tic, is characterized by a loud honking or barking cough, disruption of normal activities, and frequent presence of secondary gain (such as school absence). It is frequently preceded by upper respiratory tract infection and often is worsened in the presence of parents, teachers, and health care professionals. Habit cough is a diagnosis of exclusion and usually responds to behavioral modification techniques rather than pharmacotherapy.
Although it is difficult to differentiate psychogenic cough and vocal tic from each other, the characteristic features of both pictures helped in the differential diagnosis in our cases (7, 8).
Psychogenic cough usually occurs after the age of five years and completely disappears during sleep and activity.
Cough is substantially notable with its barking-like, noisy and explosive and severe features. Increase in cough when focused on cough and decrease in cough in the absence of the parents or other caregivers are typical for psychogenic cough.
Psychogenic cough is directly related with the anxiety of the child. Anxiety triggers and exacerbates cough. It is known that this condition is resistant to drugs (4, 7–9).
Tics are defined as rapid and repetitive muscle contractions manifested by involuntary movements or sounds. Tic disorders are included in the class of neuropsychiatric disorders.
Typical vocal tics which are observed in tic disorders characterized with motor and vocal tics include clearing the throat, grunting, snuffling from the nose and cough.
Individuals with tic disorder can supress their tics for a few minutes or hours. However, especially young children are not aware of their tics or consider them irresistable. Tics decrease in sleep and during relaxation or when the individual concentrates in any activity.
Vocal tics generally occur after motor tics or accompany them. They are instant, rapid and may start following respiratory tract diseases.
Tics are expected to initiate between the ages of two years and 15 years.
Presence of similar complaints in family members and accompaniment with psychiatric disorders including ADHD, OCD, other anxiety disorders, anger control problems and trichotillomania are frequent. The frequency and severity of tics are related with the child’s anxiety level and response to drugs is substantially well (10–14).
The most commonly used drugs in clinical practice is dopamin receptor antagonists (antipsychotic agents) (10).
When the features of cough were questioned in assessment of our cases, it was found that cough occurred as attacks in the day time, its frequency and severity showed variance in days and even hours and marked motor tics accompanied in these cases.
When the patients were questioned in terms of accompanying disorders and familial characteristics, two patients were codiagnosed with ADHD and anxiety disorder as expected and three patients had a familial history of tic disorder.
The most commonly used dopamin receptor antagonists (antipsychotics) in treatment of tic disorders were inititated in all cases and a marked improvement was obtained in a short time.
In presence of extraordinary, stereotypical, chronic dry cough which can not be explained with any underlying physical disease, tic disorder should also be considered in addition to psychogenic cough.
Remembering tic disorders which can be diagnosed easily with detailed history and which respond substantially satisfactorily to drug treatment in the differential diagnosis will minimize the risk of unnecessary investigations and treatments in children.
Habit Cough
Habit cough or “psychogenic” cough has been described in children, adolescents, and rarely adults. The cough usually begins after an upper respiratory infection, but the cough persists long after the other respiratory symptoms resolve. Typically, the cough is harsh, barking, and nonproductive. Characteristically, it disappears during sleep or distraction and is not exacerbated by physical exercise.
Habit cough may be associated with psychosocial stressors. The most common are school problems as the frequent loud coughing can be very disruptive in a classroom and may lead to school absenteeism, which can reinforce the cough.
If habit cough is associated with school avoidance, school problems, or other emotional or behavioral problems, a comprehensive plan to treat these problems should be developed. When habit cough is not associated with these complicating factors, an explanation and reassurance will often result in a decrease in symptoms over time. Lokshin and colleagues (1991) described one approach in which the cough is described as related to a cycle in which coughing leads to bronchial irritation, which leads to further coughing. They provided the patient a distractor to “help decrease the irritation” (e.g., breathing nebulized medicine, sipping warm water).
Several types of interventions for habit cough and tic cough have been described in the literature. Treatment for simple motor tics is similar to that reported for habit cough.
Current behavioral interventions use a combination of education and suggestion, for example, “This cough started with a cold. It has now become a habit in part because each time you cough, it irritates your throat and you are more likely to cough again. We will teach you how to stop doing that.”
The child is then taught a voluntary behavior that is incompatible with maintenance of the cough, such as diaphragmatic breathing, panting, or swallowing.96,114,120
We often recommend that children carry a water bottle and have them swallow water each time they feel the urge to cough, which both inhibits the cough and may enhance mucus drainage at the same time. Finally, the parents are asked to monitor the child’s progress (i.e., keep track of how many times an hour the child coughs) and reward the child for decreased coughing.
Behavioral therapy has been demonstrated to be effective for most children with habit cough; overall, habit reversal has been found to reduce habit cough and simple phonic tics by 80% to 90%.122
Prognosis and treatment for Tourette’s disorder is very different than that for habit cough or simple transient tic disorder, and the patient suspected of having TS should be referred to a neurologist or psychiatrist.
Treatment for TS usually includes psychopharmacologic interventions in addition to psychotherapy focused on behavioral strategies to decrease tics and how to cope with the illness in general. At least 20 agents have been tested for the more severe tics of TS. The most effective are pimozide, haloperidol, and clonidine. These are occasionally used for chronic tics.
For example, in one description of nine cases of psychogenic cough tic six of nine children were treated with tranquilizers to alleviate symptoms.116
Habit cough should be in the differential of every cough persisting more than 2 weeks without any laboratory, pulmonary function, or radiographic abnormalities. Children and parents should be informed that the cough does not reflect any dangerous pathology and is indeed a habit at this point.
Children should then be given a behavioral intervention that teaches them to suppress the cough and that allows a face-saving way out of the now dysfunctional habit/pattern. For most children, this approach is successful.
If, however, evidence of more than one tic or strong family history for tic disorder exists, referral to a neurologist or pediatric psychiatrist should be considered.
Likewise, if a straightforward behavioral approach is unsuccessful or if comorbid secondary psychiatric problems seem now to contribute to maintenance of the cough, referral to a pediatric psychiatrist or psy-chologist for further evaluation and treatment would be recommended.
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