ArticlePDF Available
Received: 6 February 2018
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Accepted: 7 February 2018
DOI: 10.1002/ppul.23979
COMMENTARY
The habit cough: Diagnosis and treatment
Miles Weinberger MD
1,2
1
University of Iowa, Iowa City, Iowa
2
University of California San Diego, Rady Children's Hospital, San Diego, California
Correspondence
Miles Weinberger, MD, University of California San Diego, Rady Children's Hospital, San Diego, CA.
Email: miles-weinberger@uiowa.edu
Doctors Wright and Balfour-Lynn from the Royal Brompton Hospital in
London described the diagnostic characteristics of the Habit Cough in
55 children seen over a 6-year period.
1
The ages of the 55 children
(median 10 years) were virtually identical to that of the 140 children
in whom we made that diagnosis over a 20-year period at the
University of Iowa.
2
The prior duration of the cough was also similar,
median 3 months seen at Brompton Hospital and 4 months at our
clinic. Like our experience in Iowa, the doctors at the Brompton found
that a frequent repetitive cough totally absent once asleep was a
generally sufficient characteristic to warrant the diagnosis. However,
the similarity ended after the diagnosis was made. While many of the
Brompton patients continued to cough, some for weeks or months, the
patients in Iowa left the clinic without the cough
The Brompton physicians limited treatment to explanation
and reassurance. Similar to a report of children with this problem
from Mayo Clinic, (Rochester Minnesota)
3
more than 25 years
ago, many had persistent symptoms of this debilitating disorder
for weeks or longer. It was over 50 years ago that Dr. Bernard
Berman, a Boston allergist, termedthedisorderasHabitCough,
and described an effective treatment for this disorder in six
children, using measures that he described as relying solely on
the art of suggestion.
4
Stimulated by Dr. Berman's experience, we began to use a
suggestion therapy method in our clinic at the University of Iowa. Our
approach emphasized empowering the child with the ability to resist
the urge to cough and thereby interrupt what appeared be a vicious
cycle where the cough produced a focus of irritation in the airway that
acted as the nidus for the continued cough. Our initial report in 1991
described 9 children, median age 11 years, whose repetitive sustained
cough present for up to 2 years (median 2 months) was stopped using a
form of suggestion therapy during the clinic visit.
5
Cessation of the
cough occurred within 15 min of the suggestion therapy session
(30 min for 1 very skeptical very bright male adolescent). A 1 week
follow-up found one child with no recurrences and eight with minor
transient return of symptoms self-controlled with utilization of the
autosuggestion technique taught during the clinic visit (Table 1). Seven
of the nine could be contacted a median of 2.2 years later. Sustained
absence of cough was reported for those seven. A psychological
questionnaire, the SCL-90-R, completed by the families of those seven,
identified no abnormalities.
Following our initial report, we continued that diagnostic and
treatment approach. Diagnosis in the Pediatric Allergy and Pulmonary
Clinic at the University of Iowa was based on the same criteria
described in the Brompton report, a frequent repetitive cough totally
absent once asleep. Eighty-five patients seen over a 20-year period
had the typical cough present when seen in our clinic. Those patients
were treated with suggestion therapy by one of six pediatric
pulmonologists. Cessation of cough was accomplished with suggestion
therapy by the attending clinician in all but three patients. Details of
the treatment failures are described in a subsequent review of the
subject.
6
Fifty-five patients seen during the 20-year period had a
convincing history of active habit cough but were not coughing during
the clinic visit. Where cough was not present when seen in the clinic,
autosuggestion, the same principle as our suggestion therapy was
taught so that the child could prevent any return of cough from again
becoming chronic (Table 1). Patients were instructed to contact us for
return of cough that could not be managed with the autosuggestion
techniques. That occurred only once, where the pulmonologist seeing
the patient misdiagnosed a 9-year-old girl with nocturnal coughing as
habit cough.
Another method for treating habit cough was known as the
bedsheet technique.
7
This involved wrapping a bedsheet tightly
around the child's chest with the strong suggestion that his would
enable cessation of coughing. We utilized that once when a young
immature child was unable to focus during a suggestion therapy
session. Hypnosis, which can be considered as a type of suggest
therapy, has also been described as effective for this disorder.
8
With
various methods of suggestion therapy that can be utilized by the
Pediatric Pulmonology. 2018;53:535537. wileyonlinelibrary.com/journal/ppul © 2018 Wiley Periodicals, Inc.
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535
practicing pediatric respiratory specialist and success described since
Dr. Berman's report in 1966, there should be no justification for this
chronic functional cough to continue for most children and
adolescents once the diagnosis is made. I have seen our experience
in Iowa reproduced at other institutions. Just recently, a first-year
allergy/immunology fellow at my current institution joyfully told me
1 day how she diagnosed habit cough and successfully treated a 10-
year-old boy she saw in her clinic using the principles described in our
previous publications.
As to the parents that did not accept the explanation of habit
cough at the Brompton, if the actively coughing child stops coughing
during the suggestion therapy session, the nature of the cough is then
self-evident. Explaining the self-perpetuation of the cough to the
parents should follow the suggestion therapy session. Once the cough
is stopped in the clinic, the patient should be told that they, and not the
doctor, stopped the cough. Since the urge to cough has been observed
by us to persist for up to a day after successful cessation,
autosuggestion was taught to used for any recurrences (described at
the bottom of Table 1).
The Brompton physicians reviewed some of the confusion
regarding the diagnostic terminology of this disorder. A publication
from an Expert Panelmade up predominantly of physicians with adult
specialties, pulmonologists and neurologists, lumped together all age
groups with chronic functional cough.
9
Attributing the chronic
repetitive cough without an apparent cause to a tic disorder,
psychopathology, or just calling it a somatic cough disorder has not
been helpful in either understanding or treating this disorder. Parents
are likely to be disturbed at the suggestion that their child has a
psychological problem or a tic disorder (they have often heard of
Tourette's syndrome). However, a review of published case reports
found this problem predominantly affects children and adolescents.
10
The clinical characteristics of the small number of adults described with
persistent functional cough may be different than that seen by the
Brompton doctors or us in children and adolescents. The median age
for this disorder was about 10 years at both the Brompton and Iowa
clinics with a range that decreased inversely with adolescent ages
(Figure 1).
The habit cough is not rare. With the Brompton and our
experience at the University of Iowa averaging nine and seven per
year, respectively, it is likely that similar numbers will be seen at other
referral centers. This troublesome disorder is associated with
substantial morbidity, misdiagnoses, and inappropriate medical
treatment. Consistent with the advice in the publication from the
TABLE 1 Major elements of suggestion therapy to stop the habit cough
Approach the patient with confidence that the coughing will be stopped.
There is no value in providing an explanation for the parents first beyond saying that you will show the child how to resist the urge to cough. The
explanation will be self-evident if the cough is stopped. The parents are asked to simply sit quietly with cell phones off.
Explain the cough to the child as a vicious cycle that started with an initial irritant, perhaps a cold, that is now gone. Now cough itself is the cause of
irritation that then causes more cough.
Instruct the patient to concentrate solely on holding back the urge to cough, for an initially brief timed period, for example, one-half of 1 min.
Progressively increase this time period and utilize an alternative behavior, such as sipping lukewarm water or inhaling a soothing cool mist from a
vaporizer, to ease the irritation.
Tell the patient that each second the cough is delayed makes it easier to suppress further coughing.
Keep the patient focused by continuing to provide repetitive instructions. Emphasize that holding back a cough is difficult and takes a lot of
concentration, but providing reassurance that the patient can do it.
Repeat expressions of confidence that the patient is developing the ability to resist the urge to cough; it's becoming easier to hold back the cough,
isn't it(nodding affirmatively generally results in a similar affirmation movement by the patient).
When ability to suppress cough is observed (usually by about 10 min), ask in a rhetorical manner, Youre beginning to feel that you can resist the
urge to cough, arent you?(said with an affirmative head nod).
Discontinue the session when the patient can repeatedly respond positively to the question, Do you feel that you can now resist the urge to cough
on your own?This question is only asked after the patient has gone 5 min without coughing.
Autosuggestion: Express confidence that if the urge to cough recurs that the patient can do the same thing at home. We called this autosuggestion.
This involved expressing confidence that 15-min sessions at home concentrating on holding back the urge to cough using sips of lukewarm water
to ease the irritation causing cough.We emphasized that there should be no distractions from parents or sibs; this was the child's activity. For
patients with a convincing history of habit cough but were not coughing when seen, we provided autosuggestion instructions while reassuring the
patient that they would then be able to stop the cough.
FIGURE 1 Age of diagnosis of 140 children and adolescents
diagnosed with habit cough at the University of Iowa Pediatric
Allergy & Pulmonary Division over a 20 year period (with permission
from J Allergy Clin Immunl-Practice)
536
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WEINBERGER
Brompton, the diagnosis in Iowa was also made by the characteristic
history of a repetitive cough that is absent once asleep. Little or no
testing is generally justified. Wright and Balfour-Lynn treated by
reassuring the parents and waiting for eventual cessation. For some
that means weeks or months of a continued troublesome cough before
attrition occurs. Specifics of treatment methods in the literature have
varied, but the unifying principle is suggestion that empowers the
patient with the ability to break the cycle of cough stimulating further
cough. If the cough is present when seen by the physician, showing the
patient how to stop the cough provides a cure and should be done by
all pediatric pulmonologists encountering this problem.
ORCID
Miles Weinberger http://orcid.org/0000-0003-2341-2094
REFERENCES
1. Wright MFA, Balfour-Lynn IM. Habit-tic cough: presentation and
outcome with simple reassurance. Pediatr Pulmonol. 2018;15.
2. Weinberger M, Hoegger M. The cough without a cause: the habit
cough syndrome. J Allergy Clin Immunol. 2016;137:930931.
3. Rojas AR, Sachs MI, Yunginger JW, OConnell EJ. Childhood
involuntary cough syndrome: a long-term follow-up study [abstract].
Ann Allergy. 1991;66:106.
4. Berman BA. Habit cough in adolescent children. Ann Allergy.
1966;24:4346.
5. 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;67:579582.
6. Weinberger M, Lockshin B. When is cough functional, and what to do?
Breathe (Sheff). 2017;13:2230.
7. Cohlan SQ, Stone SM. The cough and the bedsheet. Pediatrics.
1984;74:1115.
8. Anbar RD, Hall HR. Childhood habit cough treated with self-hypnosis.
J Pediatr. 2004;144:213217.
9. Vertigan AE, Murad MH, Pringsheim T, et al. Somatic cough syndrome
(previously referred to as psychogenic cough) and tic cough
(previously referred to as habit cough) in adults and children: chest
Guideline and Expert Panel Report. Chest. 2015;148:2431.
10. Lokshin B, Weinberger M. The habit cough syndrome: a review. Amer J
Asthma Allergy Peds. 1993;7:1115.
How to cite this article: Weinberger M. The habit cough:
Diagnosis and treatment. Pediatric Pulmonology.
2018;53:535537. https://doi.org/10.1002/ppul.23979
WEINBERGER
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... In some children, the quality of cough is recognizable and suggestive of specific etiology ( Table 2). [34][35][36][37][38][39][40][41] This significantly differs from adults where detailed questioning of the characteristics and timing of cough were not diagnostically useful. 42 Non-specific cough is more likely to resolve without specific treatment. ...
... Somatic Cough Syndrome and Tic Cough: Since publication of the CHEST guidelines on somatic cough syndrome and tic cough, 9 recent pediatric data primarily emanating from retrospective studies suggest that the 'habit cough' label is used 36,123 and this was considered appropriate by a minority of the panelists. However, the DSM-5 classification of psychiatric and psychological disorders no longer recognizes the habit or psychogenic terms and neurologists prefer to consider a 'habit cough' a vocal tic disorder. ...
... 128 In a Swedish communitybased study using DSM-III criteria, 0.3% were girls and 0.7% were boys in children aged 7 to 15 years. 127 Treatment of tic and somatic cough disorders range from simple explanation, suggestion therapy, 36,123,128,130 hypnosis and biofeedback, to management of Tourette's disorder. 125,126 TB: In settings where TB is prevalent, differentiating it from the many causes of chronic cough is difficult especially in young children who are unable to expectorate. ...
Article
Background Cough is one of the most common presenting symptoms to general practitioners. The objective of this article is to collate the pediatric components of the CHEST chronic cough guidelines that have recently updated the 2006 guidelines to assist general and specialist medical practitioners in the evaluation and management of children who present with chronic cough. Methods We reviewed all current CHEST Expert Cough Panel’s statements and extracted recommendations and suggestions relating to children aged ≤14-years with chronic cough (>4-weeks duration). Additionally, we undertook systematic reviews to update other sections we considered relevant and important. Results The 8 recent CHEST guidelines relevant to children, based on systematic reviews, reported some high-quality evidence in the management of chronic cough in children (e.g. use of algorithms and management of wet/productive cough using appropriate antibiotics). However, much evidence is still inadequate particularly in the management of non-specific cough in the community. Conclusion The recommendations and suggestions related to the management of chronic cough in the pediatric age group have been based upon high quality systematic reviews and are summarized in this article. Compared to the 2006 Cough Guidelines, there is now high-quality evidence for some aspects of the management of chronic cough in children. However, further studies particularly in primary healthcare are required.
... The clinical characteristics of habit cough are sufficiently recognizable that a diagnosis is generally possible based on a history and physical examination. 4 As a pediatric specialist, I will not comment further on the implications for adult CC suggested by the observations described in this article. I will leave that to my adult medical colleagues. ...
... Habit cough is a particular cough phenotype reported in children and adolescents aged around 10 years, which is repetitive involuntary coughing in the absence of any underlying disease [96]. Although a controlled trial is still lacking, suggestion therapy aimed at educating patients to control urge-to-cough and coughing may be effective [97], which may point to a hypersensitivity component. ...
Article
Introduction: Knowledge of the pathophysiology of cough has continued to advance over recent decades. Anatomic-diagnostic protocols were the first breakthrough leading to the improvement of outcomes in patients with chronic cough but have not been always successful. The unmet clinical need has prompted revised thinking regarding the pathophysiology of and the clinical approach to chronic cough. Areas covered: The paradigm of cough hypersensitivity syndrome (CHS) has been recently proposed, wherein aberrant neuro-pathophysiology is a common etiology. This review covers major findings on chronic cough and cough hypersensitivity, particularly more focused on studies published during the recent five years and explores the clinical relevance and applicability of CHS based on current knowledge and discuss knowledge gaps and future research directions. Expert opinion: The introduction of the paradigm has provided new opportunities in managing chronic cough and evidence is accumulating to support the validity of CHS. However, it also warrants the re-appraisal of existing clinical evidence and vigorous investigation of how to refine our clinical strategy. While the paradigm of CHS highlights the importance of clinical thinking from the viewpoint of cough, the value of anatomic-diagnostic protocols should remain. Moreover, given the considerable heterogeneity in clinical presentation, cough-associated disease conditions, and treatment responses across different patients, precise molecular endotyping remains key to making further advances in clinical practice.
... Habit cough causes considerable morbidity, including wellintentioned iatrogenesis, unneeded testing, unnecessary medication, and even hospitalization. 9 Several variations of suggestion are well documented as curative for habit cough. 1,4,5,8 The current unanticipated and unintended observations reported in 3 children and 2 adults demonstrate further the amenability of habit cough to suggestion. ...
Full-text available
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Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum. Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.
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Key points: Habit cough is most commonly characterised by a repetitive loud barking cough that persists for prolonged periods.The cough interferes with normal activity and substantially decreases the quality of life.The sine qua non is the total absence of this troublesome cough once asleep.The age distribution ranges from 4 years to late adolescence, with 85% of cases occurring from 8 to 14 years of age; similar cough in adults is much less common and poorly characterised.Pharmacological treatment is ineffective.A simple behavioural approach called suggestion therapy has been applied with success by many physicians.The natural history in the absence of treatment can result in persistence for months to years. Educational aims: To increase awareness of functional cough as a non-organically caused symptom in children and adolescents.To provide the means of diagnosing a functional cough based on the distinguishing characteristics of this cause of chronic cough.To understand the principles of treating a functional cough with a simple behavioural technique called suggestion therapy. Summary: Involuntary cough without an identified underlying organic reason has been given various names and recommended treatments. Current experience in children and adolescents suggests that "habit cough" best describes this entity, and suggestion therapy is a highly effective treatment that most physicians can learn.
Full-text available
Article
We conducted a systematic review on the management of psychogenic cough, habit cough, and tic cough to update the recommendations and suggestions of the 2006 guideline on this topic. We followed the CHEST methodological guidelines and the GRADE framework. The Expert Cough Panel based their recommendations on data from the systematic review, patients' values and preferences and the clinical context. Final grading was reached by consensus according to Delphi methodology. The results of the systematic review revealed only low quality evidence to support how to define or diagnose psychogenic or habit cough with no validated diagnostic criteria. With respect to treatment, low quality evidence allowed the committee to only suggest therapy for children thought to have psychogenic cough. Such therapy might consist of non-pharmacological trials of hypnosis or suggestion therapy or combinations of reassurance, counselling, and referral to a psychologist, psychotherapy and appropriate psychotropic medications. Based on multiple resources and contemporary psychological, psychiatric and neurological criteria (DSM-5 and tic disorder guidelines), the committee suggests that the terms psychogenic and habit cough are out of date and inaccurate. Compared to the 2006 CHEST Cough Guidelines, the major change in suggestions is that the terms psychogenic and habit cough be abandoned in favour of Somatic Cough Syndrome and Habit Cough, respectively, even though the evidence to do so at this time is of low quality.
Full-text available
Article
Nine patients with habit cough, initially misdiagnosed as asthma, were treated during a period of sustained repetitive symptoms with a brief session of suggestion therapy. Symptoms had previously been present for up to 2 years (median = 2 months). Five had been hospitalized for the cough. Evaluation revealed no physiologic or radiologic abnormality. All patients became symptom free during a 15-minute session of suggestion therapy. During the subsequent week, one remained completely asymptomatic and 8 had transient minor relapses that were readily self-controlled. Seven of the 9 could be contacted for determination of long-term outcome at periods up to 9 years (median 2.2 years) after the session. Six were totally asymptomatic; one had occasional minor self-controlled symptoms. A standardized questionnaire assessing psychologic symptoms at the time of follow-up revealed no somatization nor emotional distress. In contrast to this apparent cure, others have reported extended periods of continued symptoms in the absence of a uniform treatment plan for suggestion therapy even though the correct diagnosis was made. We conclude that the classical habit cough syndrome is amenable to immediate relief and long-term cure in most cases with a single session of appropriate suggestion therapy.
Full-text available
Article
To better understand factors associated with the development and persistence of habit cough and to report use of self-hypnosis for this condition. A retrospective chart review was performed for 56 children and adolescents with habit cough. Interested patients were instructed in self-hypnosis for relaxation and to help ignore the cough-triggering sensation. The patients' mean age was 10.7 years. The cough was triggered by upper respiratory infections in 59%, asthma in 13%, exercise in 5%, and eating in 4%. Onset of the cough occurred as early as 2 years, and its average duration was 13 months (range, 2 weeks to 7 years). There was a high incidence of abdominal pain and irritable bowel syndrome in the 50% of the patients who missed more than 1 week of school because of their cough. Among the 51 patients who used hypnosis, the cough resolved during or immediately after the initial hypnosis instruction session in 78% and within 1 month in an additional 12%. Habit cough is triggered by various physiologic conditions, related frequently to other diagnoses, and it is associated with significant school absence. Self-hypnosis offers a safe efficient treatment.
Article
Objectives: Our therapeutic approach to a habit/tic cough is simple reassurance in a single consultation. To quality assure our practice, we followed up children to determine outcomes at least 3 months after diagnosis. Design: Consecutive children diagnosed over 6 years were studied. Medical records were analyzed retrospectively and parents answered a scripted verbal survey. Results: Fifty-five patients were diagnosed (median age 9.9 years), with a median cough duration of 3 months (IQR 2-7.5 months, range up to 3 years). In 51/55 (93%) cases, cough was absent during sleep. 51/55 (93%) received prior medications with median 3 therapeutic trials, none of which resolved the cough. Follow-up was possible in 39/55 (71%) children after a median duration of 1.9 years. In 32/39 (82%), the cough had resolved completely (59% within 4 weeks, including 12% on the day), and it improved in 6/39 (15%). In the 26/39 (67%) parents who said they believed the diagnosis, there was 96% resolution of the cough, versus the 13/39 (33%) who were sceptical or disbelieving, when there was only 54% resolution. 7/39 (18%) children were later diagnosed with a tic disorder, functional symptoms, or a behavioural/psychiatric disorder. Conclusions: Habit cough can be diagnosed from the characteristic history; the crucial question is whether the cough disappears during sleep. We have shown successful long term outcomes following a single consultation with simple reassurance, but it is important that the child and parents believe the explanation. It is not uncommon for subsequent tic disorders or behavioral issues to emerge.
Article
Of 33 patients with psychogenic cough tic, 31 were successfully treated using an unusual reinforced suggestion technique. The cough usually follows an incidental upper respiratory tract infection and persists as a loud paroxysmal barking or honking sound for weeks to months. Paroxysms occur all day but cease with sleep. The diagnosis is often delayed for weeks to months while the patient is exposed to an increasing intensity of diagnostic procedures and therapy. Thirty percent of some 20 patients previously reported in the literature had been hospitalized. The reinforced suggestion technique depends upon the physician's convincing the patient that the persistent cough has weakened the chest muscles, which are now unable to contain the cough, and that a bedsheet tightly wrapped around the chest will provide the necessary support to stop the cough within 24 to 48 hours. The typical patient can produce the cough on command, has an ambivalent response to the prospect of care, is unconcerned about his symptoms, submits willingly to the examination and procedures, and is kept out of school for the duration of the cough. Findings on physical examination are normal except for abnormal gag and corneal reflexes. The gag reflex was depressed in six and absent in 20 of the 31 patients. The corneal reflex was depressed in 16 and absent in 5 of the 31 patients. These abnormal responses help to corroborate the psychogenic etiology. Early recognition of the nonorganic nature of this syndrome will reduce parental anxiety, loss of school time, risk of iatrogenic complications, and unnecessary medical and hospital expense.
The habit cough syndrome: a review
  • Lokshin
Lokshin B, Weinberger M. The habit cough syndrome: a review. Amer J Asthma Allergy Peds. 1993;7:11-15.