Psychogenic Cough: Diagnosis and Management
Terminology Update and Diagnostic Framework
The term "psychogenic cough" has been replaced with "somatic cough syndrome" in current practice, and this diagnosis should only be made after exhaustive evaluation rules out all organic causes, tic disorders, and other treatable etiologies. 1, 2
Critical Diagnostic Principles
In adults with persistently troublesome chronic cough despite thorough evaluation, diagnose "unexplained cough" rather than "psychogenic cough" to avoid stigmatizing patients with an incorrect diagnosis implying they cause their own symptoms. 1, 2 This recommendation stems from evidence that psychological manifestations in chronic cough patients are often consequences of the cough itself, not the underlying cause. 1, 2
What Must Be Ruled Out First
Before considering a psychological etiology, you must complete:
Full evidence-based chronic cough evaluation protocol to exclude organic causes (upper airway cough syndrome, asthma, gastroesophageal reflux disease, bronchiectasis, chronic bronchitis). 1, 2
Neurology/psychiatry consultation to exclude tic disorders, including Tourette syndrome, which can present with cough as a primary manifestation. 1, 2
Evaluation for laryngeal neuropathy using fiberoptic videoendoscopic (FEES) and videofluoroscopic (VFS) techniques, as neuropathic laryngeal irritation can mimic psychogenic cough. 3
Unreliable Diagnostic Features
Do NOT use the following to diagnose or exclude psychogenic/somatic cough syndrome:
Barking or honking cough quality - can occur in tracheomalacia, bronchiectasis, GERD, and upper airway cough syndrome. 1
Absence of nighttime cough - many organic causes (chronic bronchitis, GERD) also suppress during sleep due to sleep's natural cough suppression effect. 1
Presence of depression or anxiety - these commonly develop as consequences of chronic cough affecting quality of life and often improve when the cough resolves. 1
Diagnostic Criteria for Somatic Cough Syndrome
The diagnosis requires:
Somatic symptoms causing significant distress or disruption to daily life. 2
Excessive thoughts, feelings, or behaviors related to symptoms, manifested by disproportionate concern about symptom seriousness, persistently high anxiety about health, or excessive time/energy devoted to symptoms. 2
Persistent symptomatic state lasting more than 6 months. 2
Improvement with behavioral or psychiatric interventions after organic causes have been excluded. 2
Suggestive Features in Children (Not Diagnostic)
In pediatric patients, the following may suggest but do not confirm the diagnosis:
- Cough worsening with parental/teacher/provider presence 2
- Preceding upper respiratory infection 2
- School phobia or secondary gain 2
- "La belle indifference" (apparent lack of concern about symptoms) 2
These features are even less reliable in adults and should not be used diagnostically. 1
Evaluation for Underlying Psychosocial Factors
Screen all patients with chronic unexplained cough for:
These somatization-associated conditions may respond to targeted treatment. 1, 2 In children, conversion disorder (21.9%) and mixed anxiety-depressive disorder (12.2%) are the most common underlying psychiatric conditions. 1
Treatment Algorithm
First-Line Treatment: Behavioral Interventions
Psychotherapy, not medication, is the first-line treatment for somatic cough syndrome. 4
For Children:
- Suggestion therapy is the principal treatment approach, aiming to help the child establish control over the cough and break the cough-irritation cycle. 1, 2
- Additional techniques: self-hypnosis, speech therapy techniques, behavioral intervention. 1, 2
- Multidimensional approaches combining multiple modalities. 1
For Adults:
- Cognitive Behavioral Therapy (CBT) comprising 12-22 weekly sessions, including psychoeducation, exposure with response prevention, behavioral experiments, and relapse prevention. 4
- Biofeedback-assisted relaxation training combined with psychotherapy has shown success in case reports. 5
- Motivational interviewing techniques to increase engagement, especially at treatment initiation. 4
Treatment of Underlying Conditions
Target identified psychosocial problems:
- Treat anxiety and depression with appropriate psychiatric interventions. 1, 2
- Address domestic violence or abuse situations. 1, 2
- Treat somatization-related cardiorespiratory complaints. 1
Pharmacotherapy Considerations
No antitussive agent has been studied in randomized controlled trials for psychogenic/somatic cough syndrome. 1 Various antitussives have been used as short-term adjuncts without rigorous evidence. 1
If tic disorder is diagnosed:
- Dopamine receptor-blocking drugs (neuroleptics) are effective. 2
- Pimozide is superior to haloperidol in efficacy and side effects for Tourette syndrome. 2
If laryngeal neuropathy is identified:
- Gabapentin has shown benefit in case reports for neuropathic laryngeal irritation presenting as chronic cough. 3
Critical Pitfalls to Avoid
Never diagnose psychogenic/somatic cough before completing exhaustive organic evaluation and ruling out tic disorders. 1, 2
Never use cough characteristics alone (barking quality, absence at night) as diagnostic criteria. 1
Never assume psychological distress is the primary cause rather than a consequence of chronic cough's impact on quality of life. 1, 2
Never reinforce illness behavior through excessive focus on symptoms or providing unnecessary aids. 4
Never take a dismissive approach that fails to acknowledge the involuntary nature of symptoms. 4
Never overrely on pharmacotherapy, which has limited evidence for treating conversion symptoms directly. 4
Key Therapeutic Principle
Provide clear, empathetic explanation of the diagnosis that acknowledges the involuntary nature of symptoms - this is crucial for treatment success and patient engagement. 4