What is the treatment for psychogenic cough?

Treatment of Psychogenic Cough

Psychological counseling or psychiatric intervention should be the primary treatment for psychogenic cough after other causes have been ruled out through extensive evaluation. 1

Diagnosis and Evaluation

Before initiating treatment for psychogenic cough, it is essential to establish the diagnosis through a comprehensive evaluation:

• The diagnosis of psychogenic cough (now termed somatic cough syndrome) should only be made after an extensive evaluation has ruled out:

  • Tic disorders
  • Tourette syndrome
  • Other organic causes of chronic cough 1

• Diagnostic features to note (though not definitive):

  • Cough may have a barking or honking quality (present in some but not all cases)
  • Cough may be absent during sleep (though this is not a reliable diagnostic criterion)
  • Cough is typically suppressible, distractible, and variable 1

Treatment Approach

First-line Treatment:

1. Behavioral Interventions:

   • Suggestion therapy - helping the patient establish control over the cough 1
   • Self-hypnosis techniques 1
   • Speech therapy techniques 1
   • Behavioral modification therapy 1, 2
   • Relaxation techniques 2, 3

2. Psychological Interventions:

   • Psychotherapy to address underlying psychological factors 1, 2
   • Cognitive-behavioral therapy, especially when anxiety is present 4
   • Play therapy (particularly for children) 4
   • Psychoeducation for patients and parents 4

Second-line Treatment:

1. Pharmacological Approaches:

   • For cases with comorbid anxiety:
     • SSRIs (e.g., escitalopram) may be beneficial in cases with significant anxiety 4
   • Short-term adjunctive therapy with antitussive agents may help control the cough initially, though no agent has been studied in randomized controlled trials for this condition 1

2. Multidimensional Approaches:

   • Biofeedback-assisted relaxation training combined with psychotherapy 2
   • Physical therapy in combination with psychological interventions 2

Special Considerations

For Children:

• Parental psychoeducation is crucial 4
• Address any underlying family dynamics (e.g., punitive parenting, sibling rivalry) 4
• Play therapy may be particularly effective 4
• Consider ambulatory cough monitoring to objectively document the pattern (absence during sleep supports psychogenic etiology) 5

For Adults:

• Biofeedback-assisted relaxation training has shown success 2
• Combined approach of speech therapy, relaxation techniques, breathing exercises, and psychotherapy 2

Common Pitfalls and Caveats

• Avoid stigmatizing patients with a diagnosis implying they are causing their own cough; consider using the term "somatic cough syndrome" rather than "psychogenic cough" 1
• Remember that psychological manifestations may be a result of the cough rather than its cause 1
• Evaluate for common psychosocial problems such as anxiety, depression, domestic violence, and in children, potential abuse or neglect 1
• Avoid prolonged trials of inappropriate medications (antibiotics, asthma medications) when the diagnosis of psychogenic cough is established 3, 6
• Be aware that mentioning the word "cough" or similar terms may trigger episodes in some patients 6

Follow-up and Monitoring

• Regular follow-up to assess response to treatment
• Consider objective cough monitoring to document improvement 5
• Assess for resolution of any comorbid psychological conditions

The evidence for treating psychogenic cough is primarily based on case reports and expert opinion rather than high-quality randomized controlled trials. However, behavioral and psychological interventions have consistently shown benefit across multiple case reports and should form the foundation of treatment.