Treatment of Cough with Psychological Component
Before labeling a chronic cough as psychogenic, you must first complete an extensive evidence-based evaluation to rule out all organic causes, tic disorders (including Tourette syndrome), and uncommon etiologies—only then, if the cough improves with behavioral or psychiatric interventions, can this diagnosis be considered. 1
Critical Diagnostic Framework
This is a Diagnosis of Exclusion
In adults, the ACCP guidelines explicitly recommend diagnosing "unexplained cough" rather than "psychogenic cough" when chronic cough persists despite thorough evaluation and failed behavioral/psychiatric therapy. 1 This approach prevents stigmatizing patients with an incorrect diagnosis implying they are causing their own symptoms. 1
Essential Exclusions Before Considering Psychological Etiology
- Rule out tic disorders first: Upper airway cough syndrome, transient tic disorder, chronic vocal tic disorder, and Tourette syndrome must be excluded, often requiring neurology/psychiatry consultation. 1
- Rule out organic causes: Complete the standard evidence-based chronic cough evaluation protocol before considering psychological factors. 1
- Critical caveat: Psychological manifestations in chronic cough patients are often consequences of the cough (affecting quality of life), not the cause. 1 Do not assume psychological symptoms mean psychogenic cough.
Clinical Features (Suggestive but NOT Diagnostic)
In children, these features may suggest but do not confirm psychogenic cough: 1
- Barking or honking quality (though this alone cannot diagnose or exclude psychogenic cough) 1
- Absence during sleep (though presence or absence of nighttime cough should NOT be used diagnostically) 1
- Cough worsens with parental/teacher/provider presence 1
- Preceded by upper respiratory infection 1
- School phobia, secondary gain, or "la belle indifference" 1
In adults, these characteristics are even less reliable and should NOT be used to diagnose or exclude psychogenic cough. 1
Treatment Algorithm
Step 1: Screen for Underlying Psychosocial Disorders
Evaluate for anxiety, depression, domestic violence, and (in children) abuse/neglect—these somatization-associated conditions may respond to targeted treatment. 1
- Children with psychogenic cough commonly have conversion disorder (21.9%) or mixed anxiety-depressive disorder (12.5%). 1, 2
- Adults may have cardiorespiratory complaints from somatization that respond to treatment of anxiety, depression, or domestic violence. 1
Step 2: Behavioral and Psychological Interventions (Primary Treatment)
For children, suggestion therapy is the principal treatment approach, based on the premise that establishing cough control can break the cough-irritation cycle. 1
Specific techniques reported (though evidence is limited to non-randomized case series): 1
- Suggestion therapy and behavioral modification
- Self-hypnosis
- Speech therapy techniques
- Breathing exercises and relaxation training
- Biofeedback-assisted relaxation (reported successful in adult case) 3
- Wrapping bed sheet around chest
- Multidimensional approaches combining above methods
For adults and children with troublesome psychological manifestations, psychological counseling or psychiatric intervention should be encouraged after ruling out other causes. 1
Step 3: Adjunctive Pharmacotherapy (Limited Evidence)
- No antitussive agent has been studied in randomized, double-blind, placebo-controlled trials for habit or psychogenic cough. 1
- Various antitussive agents have been used as short-term adjuncts to help control cough, but without rigorous evidence. 1
- For tic disorders (if identified): Dopamine receptor-blocking drugs (neuroleptics) are effective; pimozide is superior to haloperidol in efficacy and side effects for Tourette syndrome. 1
Step 4: Address Quality of Life Impact
Managing psychological, physiological, and situational factors—not just identifying the cough cause—is essential to maximize improvement in cough quality of life. 4
- Improvement in anxiety symptoms significantly correlates with improved cough quality of life. 4
- Depression and stress symptoms often improve with treatment at 3 and 6 months. 4
- Address associated issues like urinary incontinence and ability to speak. 4
Key Clinical Pitfalls to Avoid
Do not diagnose psychogenic cough prematurely: This is only appropriate after extensive evaluation, ruling out tic disorders, and demonstrating improvement with behavioral/psychiatric therapy. 1
Do not use cough characteristics alone: Barking/honking quality or absence at night are suggestive in children but not diagnostic; in adults, these features should not be used at all. 1
Do not assume causation: Psychological distress in chronic cough patients is often secondary to the cough's impact on quality of life, not the primary cause. 1
In children, individualize depth of investigation: Some investigations may increase morbidity, so balance thoroughness with potential harm. 1
If all interventions fail in adults: Diagnose "unexplained cough" rather than psychogenic cough to avoid stigmatization. 1