Peer Reviewed

Photoclinic

Habit Cough

Author:
Miles Weinberger, MD
Professor Emeritus, University of Iowa; Visiting Clinical Professor of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego, California

Citation:
Weinberger M. Habit cough [published online April 10, 2019]. Pulmonology Consultant.

 

A 9-year-old girl had had a chronic cough interspersed with periods of relief for more than 2 years. She had no fever or history of other medical problems. The cough was loud and was described as sounding like a barking dog. The girl would sometimes cough for 18 hours straight. Because of the cough, she had frequently missed school, had had more than 20 visits to 3 different hospital emergency departments, and had seen 2 pediatricians, 3 otolaryngologists, 2 speech therapists, and 1 pediatric pulmonary specialist. Multiple diagnostic tests had identified no cause for her chronic cough.

She had been treated with bronchodilators and several antibiotics and had gained excessive weight from having been prescribed corticosteroids. These treatments had had no effect on her cough. She had been hospitalized once to sedate her in an unsuccessful attempt to stop the coughing. The pulmonologist had recommended psychiatric help, which had been of no benefit.

At presentation, the girl’s cough was present from when she wakes up until she falls asleep. Once asleep, she does not cough. She had headaches and chest soreness from the forceful nature of the coughing. She loves school, does well there, has friends, and her only source of anxiety was the cough.

Based on the clinical presentation, the girl received a diagnosis of habit cough.

Discussion: There are many causes of chronic cough in childhood. An algorithmic approach begins with a diagnosis that can be made just on the clinical presentation and proceeds to specific noninvasive tests. More invasive tests, such as bronchoscopy, are necessary when causes of the cough are not identified from those initial measures.1

However, in this patient’s case, the diagnosis is apparent from the clinical presentation. A chronic, harsh, repetitive, barking cough that is absent once the child is asleep is diagnostic of the habit cough syndrome.2-4 The mean age for this disorder has been identified as 10 years at 3 institutions, the University of Iowa,3 the Mayo Clinic in Rochester, Minnesota,5 and Royal Brompton Hospital in London, England.6 Eighty-five percent of 120 children at University of Iowa program were between 8 and 14 years of age.3

Various therapeutic approaches have been proposed, including explanation and reassurance,6 hypnosis,7 and suggestion therapy. The initial description in 1966 described cure by “the art of suggestion.”2 A technique for suggestion therapy usually effective within 15 minutes was reported in 19918 and subsequently applied successfully to all but 3 of 85 children treated at the University of Iowa over a 20 year period.3 Simply explaining the diagnosis was associated with continued coughing for weeks to months, with earlier spontaneous remission when the parents accepted the explanation that the cough was a habit and would eventually stop.6 Habit cough is not rare, with an average of 7 cases per year seen at the University of Iowa and 9 per year seen at the Royal Brompton Hospital in London.

Treatment and outcome of the case. Suggestion therapy was instructed in a manner illustrated at www.habitcough.com via Skype video conferencing because of the 3000 miles between the patient and the physician providing suggestion instruction. The suggestion therapy involved having the patient focus on listening to a continuous patter explaining habit cough, encouraging the patient to hold back the cough for a defined period of time that progressively expanded, and empowering the patient to break the cycle of cough causing more cough by the end of the 15-minute session. An analogy used in the explanation was of an itchy mosquito bite that doesn't heal until the scratching is stopped. Positive support for initial success was given, with emphasis on confidence that the patient could attain continued prevention of cough. This was followed by autosuggestion instruction, expressing confidence that the patient could do the same thing on her own if there were any tendency for the cough to return.

After suggestion therapy, the girl’s harsh repetitive coughing stopped. She continued to have the urge to cough for another day or 2 but generally controlled it, and she continues to be free of cough to the present.

References:

  1. Weinberger M, Fischer A. Differential diagnosis of chronic cough in children. Allergy Asthma Proc. 2014;35(2):95-103.
  2. Berman BA. Habit cough in adolescent children. Ann Allergy. 1966;24(1):43-46.
  3. Weinberger M, Hoegger M. The cough without a cause: habit cough syndrome. J Allergy Clin Immunol. 2016;137(3):930-931.
  4. Weinberger M. The habit cough: diagnosis and treatment. Pediatr Pulmonol. 2018;53(5):535-537.
  5. Rojas AR, Sachs MI, Yunginger JW, O’Connell EJ. Childhood involuntary cough syndrome: a long-term follow-up study [abstract]. Ann Allergy 1991;66:106.
  6. Wright MFA, Balfour-Lynn IM. Habit-tic cough: presentation and outcome with simple reassurance. Pediatr Pulmonol. 2018;53(4):512-51
  7. Anbar RD, Hall HR. Childhood habit cough treated with self-hypnosis. J Pediatr. 2004;144(2):213-21
  8. Lokshin B, Lindgren S, Weinberger M, Koviach J. Outcome of habit cough in children treated with a brief session of suggestion therapy. Ann Allergy. 1991;67(6):579-582.