Childhood habit cough treated with self-hypnosis

Hypnosis in the treatment of retrograde cricopharyngeus dysfunction: A case report

Retrograde cricopharyngeus dysfunction (R-CPD) causes an inability to belch. This case report describes the successful treatment of R-CPD with the use of hypnosis. Thereafter, the patient was able to burp small amounts of air, and was encouraged to continue his use of hypnosis as needed. Hypnosis and possibly other noninvasive treatments should be used for R-CPD before employment of more invasive and costly treatments such as botulinum toxin administration.

A whole new world of healing: exploring medical hypnotherapy for pediatric patients : A review

This narrative review aims to unravel the potential of medical hypnotherapy for the treatment of children with a variety of diseases and symptoms. Going beyond its history and assumed neurophysiology, the chances of success for hypnotherapy will be outlined per pediatric speciality, accentuated by clinical research and experiences. Future implications and recommendations are given on extracting the positive effects of medical hypnotherapy for all pediatricians.    Conclusion: Medical hypnotherapy is an effective treatment for children with specified conditions such as abdominal pain or headache. Studies suggest effectiveness for other pediatric disciplines, from the first line up to third line of care. In a time in which health is defined as 'a state of complete physical, mental and social well-being', hypnotherapy stays an underrated treatment option for children. It is a unique mind-body treatment, which true potential still needs to be unraveled. What is Known: • Mind-body health techniques become a more relevant and accepted part of treatment in pediatric patients. • Medical hypnotherapy is an effective treatment for children with specified conditions such as functional abdominal pain. What is New: • Studies suggest the effectiveness of hypnotherapy in a high variety of pediatric symptoms and disease. • Hypnotherapy is a unique mind-body treatment which potential goes far beyond its current utilization.

A Review, Update, and Commentary for the Cough without a Cause: Facts and Factoids of the Habit Cough

BACKGROUND

A habitual cough, persisting after the cause is gone, was described in a 1694 medical book. Successful treatment of this disorder known as habit cough was reported in 1966 by the "art of suggestion". The purpose of this article is to provide the current basis for diagnosis and treatment of the Habit Cough Syndrome.

METHOD

The epidemiology and clinical course of habit cough were reviewed; original data were obtained from three sources.

RESULTS

Unique clinical presentation was the basis for diagnosis of habit cough. Diagnosis was made 140 times with increasing frequency over 20 years at the University of Iowa clinic and 55 times over 6 years at a London clinic. Suggestion therapy provided more frequent cessation of cough than just reassurance. A Mayo Clinic archive of chronic involuntary cough found 16 of 60 still coughing 5.9 years after initial evaluation. Ninety-one parents of children with habit cough and 20 adults reported cessation of coughing from viewing a publicly available video of successful suggestion therapy.

CONCLUSIONS

Habit cough is recognizable from the clinical presentation. It is effectively treated in most children by suggestion therapy in clinics, by remote video conferencing, and by proxy from viewing a video of effective suggestion therapy.

Clinical characteristics in adult patients with somatic cough syndrome

Objective:

The data in regard of the clinical characteristics and diagnosis of somatic cough syndrome in adults were limited. The aim of this study was to fill that gap.

Methods:

This was a retrospective analysis of patients with somatic cough syndrome. We described clinical characteristics of adult patients with somatic cough syndrome.

Results:

Twenty-three somatic cough syndrome patients were identified in 543 adult patients with chronic cough. Psychiatric disorder of these patients was identified as anxiety (n = 8), obsessive-compulsive (n = 7), somatoform (n = 6), depression (n = 3), and cognitive bias (n = 1). Twelve patients showed abnormal results of investigations related with common causes of chronic cough, including gastroesophageal reflux, sputum eosinophilia, bronchial hyper-responsiveness, or signs of sinusitis but did not respond to the treatments directed to those conditions. All these patients were ever misdiagnosed as other causes of chronic cough. Compared to 520 non-somatic cough syndrome patients, patients with somatic cough syndrome were younger (32 (29.0–43.0) vs 42.0 (32.0–55.0) years, p = 0.013), longer disease duration (48.0 (19.5–102.0) vs 24.0 (9.0–72.0) months, p = 0.037), more common in dry cough (100% vs 57.6%, p < 0.001), and lower proportion of nocturnal cough (13.0% vs 40.2%, p = 0.009). Common cold (60.9%) was the most common initial trigger of cough and itchy throat (60.9%) was the most common accompanying symptom in patients with somatic cough syndrome. Notably, there were similar distribution in cough triggers and accompanying symptoms between two groups.

Conclusion:

In spite of much higher proportion of dry cough and smaller proportion of nocturnal cough, adult patients with somatic cough syndrome show similar clinical characteristics with other chronic cough patients, in regard of cough triggers, accompanying symptoms as well as abnormal results of investigations, which should be an important reason for misdiagnosis of somatic cough syndrome. Psychiatric disorder should be addressed in clinical management of chronic cough.

Irritant-Induced Chronic Cough Triggers: A Scoping Review and Clinical Checklist

Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.

Functional Respiratory Disorders in Children

Functional respiratory disorders (FRDs) are those characterized by respiratory symptoms without anatomic or organic etiology. Clinicians caring for children encounter these disorders and should be familiar with diagnosis and treatment. FRDs encompass the habit cough syndrome and its variants, vocal cord dysfunction, hyperventilation disorders, functional dyspnea, and sighing syndrome. Failure to identify these disorders results in unnecessary testing and medication. This article reviews the clinical presentation, manifestation, and treatment of respiratory FRDs in children. How health care providers can successfully identify and treat these reversible conditions in the clinical setting is discussed.

Wheeze and cough measurements at night in children with respiratory symptoms

Background

Nocturnal cough and wheeze are important symptoms when diagnosing any respiratory disease in a child, but objective measurements of these symptoms are not performed.

Methods

The aim of our study was to analyze the use of an automated detection system to assess breath sounds objectively in comparison to cough and wheeze questionnaires and to evaluate its feasibility in clinical practice.

Results

Forty-nine recordings of thirty-nine children were processed (asthma n = 13; cystic fibrosis n = 2; pneumonia n = 5; suspicion of habit cough n = 7; prolonged, recurrent or chronic cough n = 13), and cough and asthma scores were compared to the objective nocturnal recordings. Time for audio-validation of recordings took between 2 and 40 min (mean: 14.22 min, (SD): 10.72). Accuracy of the automated measurement was higher for cough than for wheezing sounds. Nocturnal cough readings but not wheeze readings correlated with some of the corresponding scores.

Conclusion

To our knowledge this is the first study using a new device to assess nocturnal cough and obstructive breath sounds objectively in children with a wide variety of respiratory diseases. The assessment proved user friendly. We obtained additional information on nighttime symptoms, which would otherwise have remained obscure. Further studies to assess possible diagnostic and therapeutic benefits of this device are needed.

Psychiatric comorbidity in children with psychogenic and functional breathing disorders

BACKGROUND

The present study aims to assess psychiatric diagnoses in children with psychogenic and functional breathing disorders (PFBD), which consist of children with psychogenic cough, throat-clearing tics, and sighing dyspnea, and compare them to a control group without any diagnosis of chronic medical problems.

METHODS

The participants consist of 52 children with PFBD and 42 children without any chronic medical problems. Psychiatric diagnoses were assessed via semistructured psychiatric interviews in both groups.

RESULTS

The two groups did not differ on age (PFBD group 11.25 ± 2.61, control group 11.17 ± 2.58; t = 0.14, P = .88) or sex (48.1% of the PFBD group were female, 61.9% of the control group were female; χ²  = 1.79, P = .18). 55.8% of the PFBD group and 28.6% of the control group had at least one psychiatric diagnosis according to the semistructured interviews (χ²  = 6.99, P = .008). The most common psychiatric diagnoses in the PFBD group were attention deficit hyperactivity disorder (ADHD; 17.3%), tic disorders, (15.4%), and specific phobia (15.4%). 11.5% of the cases in the PFBD group were diagnosed with somatic symptom disorder and more than half of the patients (n = 27 (51.9%)) showed clinical characteristics of tic disorders.

CONCLUSION

Psychiatric diagnoses are common in children with PFBD, and teamwork involving child psychiatrists may be essential for the management of children with PFBD.

When is cough functional, and how should it be treated?

Key points

Educational aims

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.

Diagnosis of the functional disorder called habit cough can be readily made by the unique clinical characteristicshttp://ow.ly/Al5B3094oxj

Management and diagnosis of psychogenic cough, habit cough, and tic cough: a systematic review

BACKGROUND

Several pharmacologic and nonpharmacologic therapeutic options have been used to treat cough that is not associated with a pulmonary or extrapulmonary etiology.

METHODS

We conducted a systematic review to summarize the evidence supporting different cough management options in adults and children with psychogenic, tic, and habit cough. Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched from the earliest inception of each database to September 2013. Content experts were contacted, and we searched bibliographies of included studies to identify additional references.

RESULTS

A total of 18 uncontrolled studies were identified, enrolling 223 patients (46% male subjects, 96% children and adolescents). Psychogenic cough was the most common descriptive term used (90% of the studies). Most of the patients (95%) had no cough during sleep; barking or honking quality of cough was described in only eight studies. Hypnosis (three studies), suggestion therapy (four studies), and counseling and reassurance (seven studies) were the most commonly used interventions. Hypnosis was effective in resolving cough in 78% of the patients and improving it in another 5%. Suggestion therapy resolved cough successfully in 96% of the patients. The greatest majority of improvements noted with these forms of therapy occurred in the pediatric age group. The quality of evidence is low due to the lack of control groups, the retrospective nature of all the studies, heterogeneity of definitions and diagnostic criteria, and the high likelihood of reporting bias.

CONCLUSIONS

Only low-quality evidence exists to support a particular strategy to define and treat psychogenic, habit, and tic cough. Patient values, preferences, and availability of potential therapies should guide treatment choice.

Clinical Hypnosis with Children and Adolescents-What? Why? How?: Origins, Applications, and Efficacy

This review article addresses the process, intention, and therapeutic value of clinical hypnosis with children and adolescents. A brief historical perspective is followed by a digest of the published laboratory and clinical research that has accelerated substantially over the past two decades. This review lends appropriate credence to the benefits and integration to clinical practice of this powerful tool for teaching young people self-regulation skills. The breadth of application is described, and several clinical vignettes are provided as examples of what is possible. In addition to the provision of the most relevant citations in the pediatric, psychological, and neuroscience literature, this synopsis concludes with information regarding availability of skill development training in pediatric clinical hypnosis.

Hypnosis in paediatric respiratory medicine

Hypnotherapy is an often misunderstood yet effective therapy. It has been reported to be useful within the field of paediatric respiratory medicine as both a primary and an adjunctive therapy. This article gives a brief overview of how hypnotherapy is performed followed by a review of its applications in paediatric patients with asthma, cystic fibrosis, dyspnea, habit cough, vocal cord dysfunction, and those requiring non-invasive positive pressure ventilation. As the available literature is comprised mostly of case series, retrospective studies, and only a single small randomized study, the field would be strengthened by additional randomized, controlled trials in order to better establish the effectiveness of hypnosis as a treatment, and to identify the processes leading to hypnosis-induced physiologic changes. As examples of the utility of hypnosis and how it can be taught to children with respiratory disease, the article includes videos that demonstrate its use for patients with cystic fibrosis.

Contemporary topics in pediatric pulmonology for the primary care clinician

Disorders of the respiratory system are commonly encountered in the primary care setting. The presentations are myriad and this review will discuss some of the more intriguing or vexing disorders that the clinician must evaluate and treat. Among these are dyspnea, chronic cough, chest pain, wheezing, and asthma. Dyspnea and chest pain have a spectrum ranging from benign to serious, and the ability to effectively form a differential diagnosis is critical for reassurance and treatment, along with decisions on when to refer for specialist evaluation. Chronic cough is one of the more common reasons for primary care office visits, and once again, a proper differential diagnosis is necessary to assist the clinician in formulating an appropriate treatment plan. Infant wheezing creates much anxiety for parents and accounts for a large number of office visits and hospital admissions. Common diagnoses and evaluation strategies of early childhood wheezing are reviewed. Asthma is one of the most common chronic diseases of children and adults. The epidemiology, diagnosis, evaluation, treatment, and the patient/parent education process will be reviewed. A relatively new topic for primary care clinicians is cystic fibrosis newborn screening. The rationale, methods, outcomes, and implications will be reviewed. This screening program may present some challenges for clinicians caring for newborns, and an understanding of the screening process will help the clinician communicate effectively with parents of the patient.

Somatoform respiratory disorders in children and adolescents-proposals for a practical approach to definition and classification

Somatoform respiratory disorders represent conditions with dysfunctional breathing unexplained by structural abnormalities. This heterogeneous group includes disorders with neural dysregulation of respiration (vocal cord dysfunction) or with dysregulation of the respiratory pattern (hyperventilation, sighing dyspnea), psychogenic disorders such as unjustified anxiety of suffocation, and stereotype conditions such as throat clearing or habit cough. Many symptoms are nonspecific and largely overlap with respiratory disease symptoms of somatic etiology. Most patients will present in a nonspecialized clinical setting. This article provides symptom-based criteria for the definition of somatoform respiratory disorders and their differentiation from somatic disease. Emphasis is put on clinical criteria which can be easily integrated in a routine setting. Owing to the multifaceted etiology of somatoform respiratory disorders therapeutic approaches integrating somatic medicine, respiratory therapy and psychology are crucial. The introduction of defined clinical criteria may facilitate the discrimination of somatoform respiratory disorders from somatic disorders in routine patient encounters and avoid therapeutic detours.

Nonpharmacological treatment of tics in Tourette syndrome adding videotape training to self-hypnosis

OBJECTIVE

This case series examines the practicality of using a standardized method of training children in self-hypnosis (SH) methods to explore its efficiency and short-term efficacy in treating tics in patients with Tourette syndrome.

METHODS

The files of 37 children and adolescents with Tourette syndrome referred for SH training were reviewed, yielding 33 patients for analysis. As part of a protocol for SH training, all viewed a videotape series of a boy undergoing SH training for tic control. Improvement in tic control was abstracted from subjective patient report.

RESULTS

Seventy-nine percent of the patients trained in this technique experienced short-term clinical response, defined as control over the average 6-week follow-up period. Of the responders, 46% achieved tic control with SH after only 2 sessions and 96% after 3 visits. One patient required 4 visits.

CONCLUSIONS

Instruction in SH, aided by the use of videotape training, augments a protocol and probably shortens the time of training in this technique. If SH is made more accessible in this way, it will be a valuable addition to multi-disciplinary management of tic disorders in Tourette syndrome.

Habit cough

OBJECTIVE

To review habit cough and its treatments to raise awareness of this condition as a potential cause of chronic cough.

DATA SOURCES

Relevant articles and references published between January 1, 1962, and April 30, 2008, were found through a PubMed search using the following keywords: habit cough, psychogenic cough, chronic cough, and tic cough.

STUDY SELECTION

All key relevant articles were reviewed, and the most relevant were selected for inclusion in this review.

RESULTS

Habit cough is a diagnosis of exclusion and can occur in children and adults with chronic cough. Characteristic features of habit cough include a loud honking or barking cough, disruption of normal activities, and the frequent presence of a secondary gain (such as school absence). Successful treatment has been described in several case reports and involves mostly nonpharmacologic measures.

CONCLUSIONS

It is important to consider habit cough in the differential diagnosis of chronic cough because early diagnosis can help to avoid unnecessary invasive procedures and potential iatrogenic complications.

Childhood habit cough treated with consultation by telephone: a case report

Background

Childhood habit cough has been treated successfully by making suggestions that it can be stopped, desensitization techniques, use of distractors, provision of rewards, and self-hypnosis. All of these techniques have involved personal contact between a health care provider and a patient.

Case presentation

A 5-year-old with cystic fibrosis was diagnosed with habit cough following evaluation by a pediatric pulmonologist and otolaryngologist. An expert in the treatment of habit cough provided instruction by telephone to the patient's mother regarding use of hypnotic techniques in this setting, which was associated with resolution of the cough within a week.

Conclusion

As this report describes a single patient, it is possible that his improvement was unrelated to the given advice. Therefore, it remains to be seen whether therapy by telephone for habit cough is applicable widely.

Clinical cough V: complementary and alternative medicine: therapy of cough

We review the actions of complementary and alternative medicines (CAMs) in the treatment of cough and of the conditions associated with it; in particular asthma and upper respiratory tract infections. These therapies may work (1) peripherally, at the sites in the airways and lungs at which cough is being activated, (2) in the brainstem, where the neural "cough center" is situated, or (3) at the cerebral cortex, where cough can be initiated, suppressed or modified by conscious or unconscious controls. Of the large number of trials of CAMs against cough, most are inadequate in design. It may be difficult to randomize selection. Blinding is often impossible both for the patient and the therapist, and adequate placebo controls may be difficult to devise. The patient can usually identify the "active" treatment by the taste or smell of a medicine, or from the approach and apparatus being used. Pure chemicals can be extracted from many of the herbs used as antitussives, and can be shown to be effective in randomized, blind, and controlled trials, but it does not follow that the herb itself, used in the recommended formula and shown to be antitussive, acts by this agency unless a placebo effect is ruled out. A few herbs are identified where the evidence points to a true antitussive action. Of nonherbal treatments, the few positive results are usually outweighed by the larger number of negative ones. Thus, in general, CAMs for cough are welcomed enthusiastically by the patient but lack sound evidence for their efficacy. Antitussive chemicals can be extracted from many herbs, but it is no more than a reasonable hypothesis that the herb itself acts through this pathway.

Airway clearance techniques to treat acute respiratory disorders in previously healthy children: where is the evidence?

Airway clearance techniques are an important part of the respiratory management in children with cystic fibrosis, bronchiectasis and neuromuscular disease. They are also, however, frequently prescribed in previously healthy children with an acute respiratory problem with the aim to speed up recovery. The current review explores the evidence behind this use of airway clearance techniques in children without underlying disease. Few studies have been performed; many different techniques are available and the therapies used are often poorly specified. It is necessary to name the specific airway clearance technique used in treatment rather than to just state "chest physiotherapy," a term that is often confused with chest clapping or vibration plus postural drainage. There is little evidence that airway clearance techniques play a role in the management of children with an acute respiratory problem. Physicians routinely prescribing airway clearance techniques in previously healthy children should question their practice.

User friendly hypnosis as an adjunct for treatment of habit cough: a case report

The more user friendly medical hypnosis can be, the more readily it will be accepted by patients and the medical community. Hypnosis is user friendly when it is simple to employ, and yields rapid, effective, and clinically significant results. Thus, we should define reasons for the effectiveness of such successful hypnosis methods, and provide this information to students of hypnosis. Some of the elements that may permit hypnosis to be user friendly are establishment of rapport, a belief that a symptom often has a functional role, and a flexible approach to the hypnosis encounter. This case report of a child with habit cough, illustrates the importance of these elements.

Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma

Although asthma is the most common cause of cough, wheeze, and dyspnea in children and adults, asthma is often attributed inappropriately to symptoms from other causes. Cough that is misdiagnosed as asthma can occur with pertussis, cystic fibrosis, primary ciliary dyskinesia, airway abnormalities such as tracheomalacia and bronchomalacia, chronic purulent or suppurative bronchitis in young children, and habit-cough syndrome. The respiratory sounds that occur with the upper airway obstruction caused by the various manifestations of the vocal cord dysfunction syndrome or the less common exercise-induced laryngomalacia are often mischaracterized as wheezing and attributed to asthma. The perception of dyspnea is a prominent symptom of hyperventilation attacks. This can occur in those with or without asthma, and patients with asthma may not readily distinguish the perceived dyspnea of a hyperventilation attack from the acute airway obstruction of asthma. Dyspnea on exertion, in the absence of other symptoms of asthma or an unequivocal response to albuterol, is most likely a result of other causes. Most common is the dyspnea associated with normal exercise limitation, but causes of dyspnea on exertion can include other physiologic abnormalities including exercise-induced vocal cord dysfunction, exercise-induced laryngomalacia, exercise-induced hyperventilation, and exercise-induced supraventricular tachycardia. A careful history, attention to the nature of the respiratory sounds that are present, spirometry, exercise testing, and blood-gas measurement provide useful data to sort out the various causes and avoid inappropriate treatment of these pseudo-asthma clinical manifestations.

Botulinum Toxin A: A Novel Adjunct Treatment for Debilitating Habit Cough in Children

Vocal fold injection with botulinum toxin type A (BTX-A) may be used as an adjunct treatment for habit cough in children. We conducted a retrospective review of 3 cases involving children aged 11 to 13 years with habit cough treated with vocal fold injection of BTX-A. Injections of BTX-A to the thyroarytenoid muscles were effective in breaking the cough cycle in all 3 children. Their coughs recurred but were controlled with 4 to 8 sessions of behavioral therapy. Behavioral therapy remains the first-line treatment, but BTX-A may be a useful complement to behavioral therapy in patients who fail standard treatments or in those with severe cough who have limited or delayed access to mental health professionals. This is the first report, to our knowledge, on the use of BTX-A in the treatment of a habit cough.

The relationship between psychogenic cough and the diagnosis and misdiagnosis of asthma: a review

The differential diagnoses of persistent nonproductive cough include numerous pulmonary and nonpulmonary organic disorders as well as functional illnesses. Many diseases can cause cough, and several studies have shown asthma among the most common etiologies associated with chronic cough in adult nonsmokers, as well as children. Psychogenic cough and its relationship to asthma and other asthma-like illnesses is complex since distinct maladies with similar features may coexist individually or in combination in any given patient. While chronic cough may occur as a sole presenting manifestation of bronchial asthma in all age groups, recent findings suggest that most children with persistent cough without other respiratory symptoms do not have asthma. Since several organic, as well as functional diseases, may present with persistent cough as their sole manifestation in either adults or children, cough should not be used as a single or major determinant to diagnose and treat asthma, especially when empirically focused therapy trials fail. Given the range of illnesses causing cough, no single management guideline can be expected to be universally effective.

Practitioner review: clinical applications of pediatric hypnosis

BACKGROUND

Over the past quarter century, hypnosis has been employed in a broad range of pediatric clinical settings; however, its efficacy and feasibility as a treatment approach for children and adolescents remain in question.

METHOD

Published studies on the role of clinical hypnosis in the management of specific pediatric medical and psychological conditions were identified and reviewed.

RESULTS

Pediatric clinical hypnosis has been employed in diverse medical settings to treat primary conditions (e.g., enuresis), as well as to address factors related to management of the condition (e.g., skills training for asthma) or its treatment (e.g., burn dressing changes). Despite great breadth to the possible applications of pediatric hypnosis and many reported successes, much of the present research comprises case histories and small, uncontrolled group studies.

CONCLUSION

To date, research in pediatrics views clinical hypnosis as a promising tool with the potential to help manage a variety of conditions. However, additional research, particularly utilizing randomized, controlled methodologies and adequate sample sizes, is required.

Psychogenic cough in an asthmatic child: case report with unusual findings

A 9-year-old girl with known mild intermittent asthma presented with a persistent cough. Her cough exhibited a four-beat staccato rhythm, was nonproductive, and persisted only while awake. On physical examination, she displayed several unique findings not previously described. An extensive yet non-diagnostic medical workup coupled with absence of aggressive medical treatment for the more usual causes of cough lead to psychologic investigation and intervention with subsequent cough resolution. The appropriate use of psychologic consultation, testing, and success with supportive reinforcement therapy confirmed a psychogenic etiology. Extended medical follow-up of the patient concerning cough reoccurrence remains uneventful.

Supramedullary influences on cough

The evidence for supramedullary influences on cough is largely indirect. Cough can be voluntarily induced or inhibited, functions usually thought to reside in the cerebral cortex. A sensation of 'urge-to-cough' usually precedes cough due to an airway irritant stimulus, and this may well involve the cerebral cortex. In conditions with interruption of the pathways between the cortex and the brainstem, such as strokes and Parkinson's disease, voluntary cough may be inhibited without disruption of reflex cough from the larynx or lower airways. 'Habit cough', like Tourette's syndrome, is assumed to be cortically mediated. Placebos and many treatments based on complementary medicine are effective in inhibiting clinical cough, and the site of action is likely to be the cerebral cortex. In sleep and in anaesthesia cough is depressed and, again, this seems likely to be at a cortical level. However there are few or no experimental or clinical observation as to the localization and functions of supramedullary areas responsible for cough. It is a field of research wide open for exploration.

Cough in children: definitions and clinical evaluation

The aetiology and management approach for cough in children differs greatly to that in adults, so the empirical approach commonly used in adults is unsuitable for children. Clinical evaluation of cough in children should include an assessment of environmental factors, particularly tobacco smoke, parental concerns and expectations. Most children with acute cough are likely to have an uncomplicated viral acute respiratory tract infection, but the possibility of a more serious problem, especially aspiration of foreign material, should always be considered. Isolated chronic cough in children is rarely asthma, and the term "cough variant asthma" should not be used. Over-the-counter and prescription medications are ineffective for the symptomatic relief of acute cough. Treatment for chronic cough should be based on aetiology. Because of the favourable natural history of cough, a "positive" response in medication trials should not be assumed to be due to the medication. Children should be reassessed within the expected timeframe of response to therapy.

Habit cough: assessment and management

Habit cough is a condition that is often misdiagnosed as asthma. The cough is bizarre in nature, troublesome to those around the person coughing and clearly a waking phenomenon. Often, relatives will have considered the possibility of a habit cough by the time that they present to the respiratory or general paediatrician. In the majority of cases, simple explanation of the nature of likely stressors and reassurance form the basis of effective therapy. In young people with more entrenched symptoms, the provision of coping strategies and increasing the subjective sense of control is an intervention in itself and will improve the likelihood of a good outcome. In more extreme cases, the role of rehabilitation programmes involving negotiation with schools and community organisations may prove useful in remediation of the cough and normalisation of social and peer supports.

Physiological and pathophysiological down-regulation of cough

Recent clinical studies have emphasized the up-regulation (sensitization) of cough in pathological conditions of the airways. However there are also many situations where voluntary and reflex cough can be down-regulated. These include: (1) chemical stimulation of breathing by hypercapnia or hypoxia or both, establishing that cough sensitivity can be inversely related to drive to breathing; (2) voluntary inhibition of cough, probably similar in mechanism to the depression of cough that can be induced by hypnosis and other branches of alternative medicine; (3) the placebo effect of many antitussive treatments; (4) sleep; (5) general anaesthesia; (6) central nervous disorders such as coma, stroke, Parkinson's disease and several other conditions where the defect in the protective reflexes may lead to aspiration pneumonia; (7) increased activity in various afferent inputs from viscera in the thorax and abdomen; (8) a number of bronchopulmonary clinical disorders. The list is long, but regrettably the nervous mechanisms of these down-regulations have been little studied. In addition there are a number of situations, such as exercise, coitus, talking and singing which, while important to coughing humans, have been not investigated in relation to cough. Most of the studies have been with experimental animals, and their extension to human research is desirable. In view of the importance of cough and other defensive reflexes in maintaining human well-being, far more research is needed. The field is wide-open.

Habit Cough, Tic Cough, and Psychogenic Cough in Adult and Pediatric Populations

OBJECTIVES

To review the literature on habit, tic, and psychogenic cough, and to make evidence-based recommendations regarding diagnosis and treatment.

DESIGN/METHODOLOGY

For data on adults, an Ovid MEDLINE literature review (through February 2005) was performed for all studies published in the English language, including case series and case reports, since 1966 using the medical subject heading terms "habit cough," "psychogenic cough," "tic disorder," "vocal tic," "Tourette's syndrome," "honking cough," and "barking cough." For pediatric data, articles were identified dating from 1966 from searches of the Cochrane Library, PubMed, EMBASE, the list of references in relevant publications, and the authors' collection of references with the last search performed in February 2005. The search terms used were "children" and "vocal tics" or "habit cough," or "psychogenic cough" or "chronic cough."

RESULTS/CONCLUSIONS

The methodologies used and rigor of the diagnostic and therapeutic interventions reported in the literature are inconsistent. The putative clinical characteristics of habit cough and psychogenic cough, for the most part, have not been prospectively or systematically studied. Therefore, on the basis of expert opinion, the diagnoses of habit cough or psychogenic cough can be made only after an extensive evaluation is performed that includes ruling out tic disorders and uncommon causes of chronic cough, and when cough improves with behavior modification or psychiatric therapy. In adult patients with chronic cough that remains persistently troublesome despite an extensive and thorough evidence-based evaluation, and after behavior modification and/or psychiatric therapy have failed, unexplained cough should be diagnosed rather than habit cough or psychogenic cough. In children, the depth of investigations to rule out uncommon causes must be individualized as some investigations and/or treatment may increase morbidity. In adult and pediatric patients with chronic cough that is associated with troublesome psychological manifestations, psychological counseling or psychiatric intervention should be encouraged after other causes have been ruled out.

Cough: are children really different to adults?

Worldwide paediatricians advocate that children should be managed differently from adults. In this article, similarities and differences between children and adults related to cough are presented. Physiologically, the cough pathway is closely linked to the control of breathing (the central respiratory pattern generator). As respiratory control and associated reflexes undergo a maturation process, it is expected that the cough would likewise undergo developmental stages as well. Clinically, the 'big three' causes of chronic cough in adults (asthma, post-nasal drip and gastroesophageal reflux) are far less common causes of chronic cough in children. This has been repeatedly shown by different groups in both clinical and epidemiological studies. Therapeutically, some medications used empirically for cough in adults have little role in paediatrics. For example, anti-histamines (in particular H1 antagonists) recommended as a front-line empirical treatment of chronic cough in adults have no effect in paediatric cough. Instead it is associated with adverse reactions and toxicity. Similarly, codeine and its derivatives used widely for cough in adults are not efficacious in children and are contraindicated in young children. Corticosteroids, the other front-line empirical therapy recommended for adults, are also minimally (if at all) efficacious for treating non-specific cough in children. In summary, current data support that management guidelines for paediatric cough should be different to those in adults as the aetiological factors and treatment in children significantly differ to those in adults.

Teamwork approach to clinical hypnosis at a pediatric pulmonary center

The aim of this report is to demonstrate the success of a teamwork approach for providing instruction in self-hypnosis at a Pediatric Pulmonary Center. In order to add to the hypnosis service provided by a pulmonologist at the Center, the Center social worker learned how to use clinical hypnosis. During a 3-year period, she instructed 72 patients (average age 11.6 years) in self-hypnosis. Eighty-two percent of the patients reported improvement or resolution of the primary symptoms, which included anxiety, asthma, chest pain, dyspnea, habit cough, hyperventilation, sighing, and vocal cord dysfunction. The social worker and pulmonologist consulted with each other on a regular basis regarding their hypnosis work, and achieved similar successful results following their hypnosis interventions. Thus, clinical hypnosis at a Pediatric Pulmonary Center can be provided by a team of varied professionals. As a team, these professionals can support each other in their on-going development of hypnosis skills.

Identification of children who may benefit from self-hypnosis at a pediatric pulmonary center

BACKGROUND

Emotional difficulties can trigger respiratory symptoms. Thus, children presenting with respiratory complaints may benefit from a psychological intervention. The purpose of this study was to define the proportion of patients referred to a Pediatric Pulmonary Center who may benefit from instruction in self-hypnosis, as a psychological intervention.

METHODS

A retrospective chart review was conducted for all newly referred patients to the SUNY Upstate Medical University Pediatric Pulmonary Center during an 18 month period beginning January 1, 2000. Patients were offered hypnosis if they presented with symptoms or signs suggestive of psychological difficulties. Hypnosis was taught in one or two 15-45 minute sessions by a pediatric pulmonologist.

RESULTS

Of 725 new referrals, 424 were 0-5 years old, 193 were 6-11 years old, and 108 were 12-18 years old. Diagnoses of anxiety, habit cough, or vocal cord dysfunction accounted for 1% of the 0-5 year olds, 20% of the 6-11 year olds, and 31% of the 12-18 year olds. Hypnotherapy was offered to 1% of 0-5 year olds, 36% of 6-11 year olds, and 55% of 12-18 year olds. Of 81 patients who received instruction in self-hypnosis for anxiety, cough, chest pain, dyspnea, or inspiratory difficulties, 75% returned for follow-up, and among the returning patients 95% reported improvement or resolution of their symptoms.

CONCLUSION

A large number of patients referred to a Pediatric Pulmonary Center appeared to benefit from instruction in self-hypnosis, which can be taught easily as a psychological intervention.

Stressors associated with dyspnea in childhood: patients' insights and a case report

OBJECTIVE

To highlight the concept that stress can be associated with dyspnea in children.

METHODS

A chart review identified 22 patients (age range, 9-17 years) referred to a pediatric pulmonologist, who were offered instruction in self-hypnosis for treatment of dyspnea that persisted despite medical therapy. Patients were offered the opportunity to use hypnosis to gain insight into the causes of their dyspnea.

RESULTS

The dyspnea resolved in 18 of the 22 patients within 1 month of instruction in self-hypnosis for relaxation and symptom reduction. Eight of the 22 patients (age range, 11-16 years) chose to use hypnosis for insight. Using automatic word processing, they explained that their dyspnea was associated with stressful situations, or that it reduced the chances of having to experience an uncomfortable situation. For example, a girl with dyspnea resulting from vocal cord dysfunction realized during hypnosis that she developed her symptom in order to prevent herself from talking about information that might cause discomfort were it disclosed. As soon as the patient decided that she could trust herself to handle the information appropriately, her symptom resolved.

CONCLUSIONS

Dyspnea may provide patients with a way of expressing their reactions to perceived or anticipated stress. Thus, stress reduction interventions may prove very helpful in resolving this symptom. However, in some cases gaining an insight into the potential cause of the dyspnea may increase the effectiveness of therapy.