Successful treatment of habit cough using suggestion therapy

Sharma P et al. Successful treatment of habit cough


INTRODUCTION
Habit cough is one of the causes of chronic cough in children.Many cases do not reach the psychiatrists due to lack of specific clinical features and diagnostic tests.We present a case of 13 year old boy with habit cough who was successfully treated by suggestion therapy and lignocaine based mouth gargle as a distracter.This case highlights that suggestion therapy can be an important treatment option to this fairly common condition.

Keywords:
Habit cough, psychogenic cough, suggestion therapy Cough is among the most common complaints of children seeking a physician's care. 1 In children psychogenic factors are known to be a possible cause of persistent cough. 2 Various terms like habit cough, psychogenic cough, and tic cough, are used to describe cases of chronic cough which has no clear pulmonary or extrapulmonary etiology and has some suggestive clinical characteristics and/or an association with psychological issue. 3Studies by Holinger and colleagues 4,5 have found habit cough to be the second most common cause of chronic cough in children aged 6 to 16 years.Habit cough is considered to be a somatic manifestation of a wide range of psychosocial problems like school phobia, family problems, and attention seeking, and the underlying cause may be related to the secondary gain produced by the coughing. 6Therefore, in children presenting with chronic cough, the diagnoses of habit cough or psychogenic cough is considered only after tic disorders and Tourette syndrome have been ruled out and when cough improves with specific therapy. 7Suggestion therapy techniques is one of the psychological means which mainly refers to the process of the physician convincing the patient that he or she can control the cough by resisting the urge to cough. 8In the process, nature of the cough is explained to the patient and the family members by the physician and confidence is expressed in patient's ability to stop the cough.We present the case of a child with habit cough who was successfully treated with suggestion therapy.

DISCUSSION
As there is lack of specific clinical features and diagnostic tests, cases of psychogenic cough have essentially become a diagnosis of exclusion. 9It has been widely accepted that that a barking or honking quality of cough and absence of cough at night are suggestive of psychogenic, habit, and tic cough as presented in the index case. 10The patient did not experience symptomatic relief from the pharmacological intervention.However, he was successfully treated with suggestion therapy augmented with lignocaine based mouth gargle as a distracter.This is supported by the evidence from a systematic review by Haydour et al. 3 where 96% of 52 patients had obtained relief using the suggestion therapy.Apart from that suggestion therapy, use of self-monitoring of the symptoms also plays a vital role as seen in the index case.In suggestion therapy use of distractors in the form of a bed sheet wrapped around the patient's chest or nebulized lidocaine diluted in normal saline have been used reported, the major role of the distractor being to help patients control their cough. 8owever, the use of lignocaine based mouth gargle have not been reported previously.
This case adds to the literature pointing towards the efficacy of suggestion therapy in management of habit cough in children. 11However, further studies are required to explore the long term efficacy of this technique.

CONFLICT OF INTEREST
None None None ACKNOWLEDGEMENT FUNDING ment.During interview; patient was euthymic and cooperative.His thought content was within normal limits for his age.He coughed throughout the assessment.Repeat consultations from pulmonary medicine, paediatrics and ENT did not reveal any organic cause for his cough.In ward observation, it was found that the intensity of coughing was reduced when patient was alone and considered himself unobserved, or when he was engaged in play activities or watching TV in the Day care.In view of investigations and clinical observation, a provisional diagnosis of psychogenic cough was considered.IQ assessment revealed an IQ of 96 (Average IQ).Childhood Thematic Apperception Test didn't reveal any underlying stressor.
Suggestion therapy was started with the patient, in which one of the co-authors (resident psychiatrist) attempted to develop therapeutic alliance with the patient.The therapist expressed confidence that he would be able to show the patient how to stop the cough.Patient was provided a strong suggestion that the cough was the response to a perceived irritation in the airway that resulted in vicious cycle of cough in response to irritation which caused more irritation and thereby more cough.The suggestion was also given that the distractor (lignocaine based gargle) would sooth this irritation, and he was instructed to use it whenever he had the urge for coughing.Thereafter he was empowered to resist the urge to cough for as long as possible.Other alternatives, such as drinking tepid water to resist the urge was also offered.The patient participated in 30 minute sessions twice daily.The therapist charted the duration for which patient was able to resist coughing to monitor progress on daily basis, gave subsequent feedback to the patient and acknowledged the efforts.Over a period of 6 weeks, the patient was successfully able to supress the urge to cough for up to 30 minutes.Gradually even in the absence of the therapist, patient started volunteering to use lignocaine based mouth gargle whenever the urge to cough occurred and was successfully able to resist the urge for more than 30 minutes.The duration and frequency of coughing also reduced from 4-6 times/ day lasting from 1-2 hours to 1-2 times in a day, lasting from 15-20 minutes.Following discharge, booster sessions of suggestion therapy were continued in the out-patient department once a week.Over next 5-6 weeks, patient was able to resist the urge to cough, without the use of lignocaine based mouth gargle and coughed only for 10-20 minutes/day.Patient maintained this improvement up to 6 months follow up and resumed school and play activities as previously.