"The Barking Girl": A Case Report of Psychogenic Cough in a Child with a Review of Literature.

A 9-year-old girl presented with 2-month history of continuous coughing; despite detailed evaluation, no organic cause was found. Considering the provisional diagnosis of a psychogenic cough, she was advised for psychiatry consultation. After a psychological assessment, she was found to have comorbid anxiety (Screen for Child Anxiety Related Disorders score- 25) along with punitive parenting and sibling rivalry issues. She was initially treated with parental psychoeducation, play therapy, and behavior therapy. Since she did not show expected progress with the treatment, low-dose escitalopram was started along with the ongoing therapy, considering her anxiety. There was a significant improvement in her symptoms in 1-month follow-up. She maintained improvement during further follow-ups. This case illustrates the need to identify and treat comorbid psychiatric issues in the management of a psychogenic cough.

INTRODUCTION

Cough as defined by the European Respiratory Society guidelines is a “forced expulsive maneuver or maneuvers against a closed glottis that are associated with a characteristic sound or sounds.”[1] Cough is said to be chronic if the duration of cough exceeds 4 weeks.[2] One of the most confusing entities among the category of chronic cough is “psychogenic cough.” Over the years, because of its dubious nature, it has acquired various nomenclatures, such as “nervous cough,”[3] “operant cough,”[4] “psychogenic cough tic,”[5] “habit cough,”[6] and “barking cough of puberty.”[7] However, none of the above terms are included in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[8] The closest term that can be used to describe this entity is “Somatic cough disorder” under “Somatic symptom disorder” (SSD) previously known as “Somatization disorder.” The DSM-5 defines it as “characterized by somatic symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms. To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least for 6 months).” This is typically a diagnosis of exclusion, which should be established after careful and thorough investigation. When organic pathology is ruled out, confusion still remains between two entities: SSD and vocal tics (as found in Tourette's syndrome). Although there are differences in the modes of presentation, the features that are common in almost all the cases of psychogenic cough reported so far are: (1) the cough is nonproductive (2) typically sounds like the “honking of a Canadian goose” or it may sound like “barking,” which is explosive and brassy in nature,[9] (3) usually it ceases at night time or on distraction, (4) increase in the intensity of cough in the presence of certain people or when the patient understands that he/she is being observed, (5) the cough is not suppressed by any medication, and (6) the cough is not aggravated by laughter, exertion, crying, or any change in environment.[10] The vocal tics also presents similarly, cough without expectorations whose intensity decreases at night. The difference can be elicited by carefully studying the effect of the individual. Tic disorder patients are typically ashamed, anxious, and self-conscious about their tics whereas patients with psychogenic coughs show typical “la belle indifference.”[11] Patients with tic disorder also present with associated motor tics which are absent in psychogenic cough. Another important point to be noted by the clinicians is the presence of strong family history in tic disorders in contrast to psychogenic cough.[12] The following case is presented to highlight those clinical features necessary to diagnose the entity and the management steps we took to control it.

CASE REPORT

Miss. SM, a 9-year-old girl presented with a 2-month history of continuous coughing and irritable mood that has increased in frequency in the past 2 weeks. The onset of the cough was abrupt which was not associated with any sore throat, fever, frequent throat clearing, or any sensation of postnasal drip. Her parents informed that the cough usually subsides while she is sleeping. At the initial phase of evolution of cough, she was admitted at a hospital and thoroughly examined; although investigations failed to yield any relevant result, a provisional diagnosis of allergic bronchitis was made and she was put on antihistamines and steroids. With the above-mentioned medications, her cough subsided in intensity and she was discharged. However, the parents informed that when they were traveling home after discharge, the cough resurfaced with similar intensity. The patient was seen by numerous physicians thereafter without any benefit. Her parents took her to a tertiary care center of national importance, where again she was thoroughly investigated (sputum test, high-resolution computed tomography of lung, a complete allergic profile, and other relevant blood investigations) for her cough. She was referred to a psychiatrist as those investigations were also unyielding. When she came to us, she made a barking type of sound which occurred in recurrent paroxysms at an interval of 30 s to 1 min and yielded no expectorations and is not associated with respiratory distress. She complained that because of the continuous cough, her chest and abdominal muscles have gotten sore, and she feels nervous and uneasy all the time. During the interview using play technique, the patient revealed that the nervousness is present for almost last 1 year with increasing intensity from the past 3 months, which started after she changed her school. It was also evaluated that there was punitive parenting from maternal side, which distressed her much. The child fidgetily admitted that her new schoolmates are “not very nice” and described one incident where she was taken to a dark room in her school unwillingly by her friends rumored to have some paranormal activities. “No immediate symptoms followed these incidents except that she distanced herself from friends and appeared nervous most of the time,” her parents reported. During the interview, one crucial point was evaluated. It was found that her brother was suffering from allergic bronchitis for the past 1½ years intermittently, for which the parents were quite concerned. “Obviously, our younger son received more attention than her before she developed this condition, as we were very concerned about frequent recurrence of it,” the parents admitted. They also revealed that she was frequently asked to adjust her lifestyle for her sick brother to which she partially complied. Evidence of sibling rivalry was present in the form of frequent episodes of fights between the siblings. Her birth and developmental history was normal without any significant family history of psychiatric illness. Mental state examination revealed an average-built girl, with inhibited temperament, proper hygiene and grooming with decreased tone, flow and volume of speech which being coherent and relevant. Her mood was anxious with appropriate affect without any formal thought disorder. Her thought contents were normal without any perceptional abnormality and intact cognitive function. Application of the Screen for the Child Anxiety Related Disorders[13] questionnaire-parent version yielded a total score of 25 indicating presence of anxiety disorder, mainly separation anxiety disorder (score-5) with significant somatic symptoms (score-8). A few psychological assessments were done before psychotherapy was initiated. The Children's Apperception Test (Projective test) revealed anxiety from being away from attachment figures and also perceived the authority figures as dominating, and the administration of Malin's Intelligence Scale for Indian Children revealed an intelligent quotient of 100 (average). Play therapy was initiated in the first few sessions as the child was very guarded. As she was good in drawing, she was made to express her feelings through drawing. Breathing exercise was taught. After the child was well engaged in therapy, suggestion therapy was initiated when she was given the confidence of controlling the urge to cough, as a way to break the pattern of coughing. Increasing time periods of controlling the cough in the session was given, i.e., for 1 min, then 3 min, then 10 min, and so on. She was positively reinforced when there was an effort to control. Her parents were made to practice the same at home and reinforce even the smallest of efforts made by her.[14] Psychoeducation was also given to the parents about parenting styles and to be more supportive and less critical. Advices were given regarding the ways of cutting down secondary gain and differential reinforcement principles. We started medications (tablet escitalopram 2.5 mg once daily) after initial few sessions considering her anxiety. Subsequent follow-up showed reduction in the frequency and “barking” tone of the cough.

DISCUSSION

Literature suggest that the prevalence of psychogenic cough is a matter of debate, it is diagnosed in around 3%–10% in children presenting with chronic cough of unknown origin.[11] However, a Chinese systematic review and meta-analysis conducted by Wei et al.[15] in 2016 reported the overall prevalence of psychogenic cough as 3.02% (95% confidence interval: 2.53%–3.60%). From a psychodynamic perspective, Bernstein and City[7] describe the cough as a “bark out” protest in a maternally dominated child. Some researchers consider it as a way of secondary gain for school phobic children,[516] whereas others consider it as a way of the children for expressing hidden dissatisfaction toward their families.[17] Grumet explained the phenomenon as “Just as weeping serves the dual function of washing irritants out of the eyes and expressing unhappiness, so does the cough share overlapping roles in discharging emotion and clearing the lungs.” Behavioral psychology explains it as a learned behavior that is shaped and maintained by environmental reinforcements, which may be positive (social attention) or negative (school avoidance). In this case, with a background of sibling rivalry, the child have identified with her brother and use the coughing behaviour to attract more parental attention and cope with the punitive parenting and school stresses. As reported by Haydour et al.,[18] suggestion therapy, hypnosis, reassurance, and counseling were the most recommended methods of intervention in these cases. The Food and Drug Administration has not approved any medication for the treatment of psychogenic cough. There is limited research on the role of pharmacotherapy in these cases. Researches have suggested the role of selective serotonin reuptake inhibitors (SSRIs) in the management of comorbid anxiety disorders in these cases, with escitalopram showing a favorable side effect profile in long-term therapy. We took a combined approach of treating the patient with SSRIs along with parental education and suggestion therapy to which the patient responded significantly. This case report thus highlights the need to identify comorbid anxiety disorder and psychosocial issues such as punitive parenting and sibling rivalry in child population presenting with unyielding chronic cough and judicious use of evidence-based treatment in its management.

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