Cough Section

Somatic cough syndrome or psychogenic cough—what is

the difference?
Anne E. Vertigan1,2,3
1Speech Pathology Department, John Hunter Hospital, Newcastle, Australia;2Centre for Asthma
and Respiratory Disease, University of Newcastle, Newcastle, Australia;3Hunter Medical Research
Institute, Newcastle, Australia

Correspondence to: Anne E. Vertigan. Speech Pathology Department, John Hunter Hospital, Locked Bag
1, Hunter Region Mail Centre, NSW 2310, Australia. Email: [email protected].

Abstract: The term psychogenic cough has been used to describe cough without obvious
medical etiology, which is refractory to medical management and considered to have a psychiatric
or psychological basis. However there are limitations in the research into psychogenic cough with
limited empirical data on how to define the condition or differentially diagnose it from other forms
of chronic cough. The term somatic cough syndrome was introduced by the American College of
Chest physicians in 2015 during their revision of the 2006 guideline on psychogenic cough.
Psychomorbidity can be present in chronic cough arising from a variety of etiologies and can
impact on symptom perception and clinical management of the condition. Psychological
symptoms can also improve after effective treatment of the chronic cough. The recently published
American College of Chest Physicians cough guidelines recommended replacing the term
psychogenic cough with the term somatic cough syndrome in order to be consistent with the
Diagnostic Statistical Manual of Mental Disorders, 5th edition (DSM-5) where the term
psychogenic is no longer used. This paper outlines the current evidence regarding psychogenic
cough, proposes a model for conceptualising psychological issues in chronic cough and
discusses strategies for clinical management of psychological issues in patients with chronic
cough.
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 Keywords: Cough; psychophysiologic disorders; depression

Submitted Feb 23, 2017. Accepted for publication Mar 09, 2017.

doi: 10.21037/jtd.2017.03.119

Psychogenic cough Other Section

The traditional view of chronic cough was that it is due to medical conditions such as
gastroesophageal reflux disease, asthma, rhinosinusitis, lung disease, non-asthmatic eosinophilic
bronchitis, and Angiotensin Converting Enzyme inhibitors or environmental exposure such as
tobacco smoking. Identifying and treating the underlying cause of the cough was thought to
reduce or eliminate cough. The terms psychogenic cough and habit cough have been used to
describe cough that has no obvious medical etiology, is refractory to medical management and is
considered to have a psychiatric or psychological basis (1). In the early literature, chronic cough
was considered to be psychogenic if it persisted despite medical treatment, demonstrated
characteristics such as a honking or barking quality, was absent during sleep, or was associated
with psychiatric illness. This review will discuss the evidence for the diagnosis and treatment of
psychogenic cough. It will explore psychogenic cough as a unique phenotype of cough and
examine psychomorbidity in relation to cough. Finally it will outline clinical implications for the
diagnosis and management of psychomorbidity in chronic cough including strategies to assist
managing the patient with suspected psychogenic cough.

Evidence for the diagnosis and treatment of psychogenic Other Section

cough

There are limitations in the research regarding psychogenic cough. In 2014, Haydour et al. (2)
conducted a systematic review of literature pertaining to psychogenic, habit and tic cough.
Eighteen studies including 233 patients were identified. This review found that the methodological
quality of the studies was poor. The diagnostic criteria for psychogenic cough were limited to the
description of symptoms by the patient. Control groups and validated cough assessment tools
were not employed. The studies involved retrospective case series or case studies with limited
prospective analysis. There was a heterogeneity of definitions and diagnostic criteria and the
possibility of reporting bias (2).
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 There are limited criteria for the diagnosis of psychogenic cough (2). For example, barking honking
cough is thought to be a characteristic feature of psychogenic cough, however, only 8 out of the
18 studies in the systematic review (2) reported this particular cough characteristic. Barking cough
has also been reported in medical conditions such as tracheomalacia (3) and bronchiectasis (4).
Psychogenic cough is often reported to be absent at night (2) yet cough due to organic disease,
such as bronchitis and gastroesophageal reflux disease (5,6), can be absent or reduced at night.
Only 4 out of 18 studies reported comorbid psychiatric disorders and only three of these included
a formal psychiatric diagnosis. It would appear that the features of psychogenic cough reported in
the literature are not unique to psychogenic cough.

The etiology of chronic cough is not always easily identified despite systematic investigation (2)
and cough can persist despite systematic assessment and treatment of the underlying cause (7).
For example, while treatment for diseases associated with chronic cough such as
gastroesophageal reflux disease or rhinosinusitis are effective in treating the underlying condition
they may be less effective in treating cough. It is possible that the psychogenic cough label has
been applied on the basis of cough being refractory to medical treatment without other supporting
evidence.

Clinical practice guidelines Other Section

Following Haydour et al.’s systematic review, the 2006 American College of Chest Physicians
(ACCP) guideline on psychogenic cough published by the American College of Chest Physicians
was updated (8). Ten recommendations were made in the guideline and are listed in Table 1.

Table 1 Recommendations from the American College of Chest

Physicians Cough guideline on psychogenic cough (8)
Full table

The guidelines replaced the term psychogenic cough with the term somatic cough syndrome (8),
in order to be consistent with terminology used in the Diagnostic Statistical Manual of Mental
Disorders, 5th edition (DSM-5). The term psychogenic has been removed from the DSM-5
classification of diseases because functional imaging studies have demonstrated cerebral
correlates for disorders previously thought to be of a pure psychogenic nature (9). Psychogenic
cough usually refers to a somatisation disorder and is distinct from malingering (10) and
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 conversion disorder (11). Somatization refers to the transfer of psychological distress into a
physical symptom (12).

The guideline also replaced the term habit cough with tic cough. A tic is defined as a repetitive
movement involving discrete muscle groups. It is a fragment of a normal motor action that is
misplaced in context (13). Key clinical features of tics include suppressibility, distractibility,
suggestibility and variability (13).

The ACCP guidelines recommend that the presence or absence of nocturnal cough or
barking/honking quality should not be used to diagnose or exclude somatic cough syndrome
(psychogenic cough). These cough characteristics can be caused by a variety of diseases and
lack specificity for a diagnosis (12). The presence of anxiety or depression should not be used as
diagnostic criteria for somatic cough syndrome.

The ACCP guidelines recommended that the diagnosis of somatic cough syndrome (psychogenic
cough) can only be made after extensive evaluation has been performed, uncommon causes of
cough are excluded, and the patient meets the DSM-5 criteria for a somatic symptom disorder.
These DSM-5 criteria include one or more somatic symptoms that are distressing or result in
significant disruption to daily life. There may be disproportionate and persistent thoughts about
the seriousness of the symptoms, high levels of anxiety about symptoms or excessive time and
energy devoted to the symptoms (10). In patients diagnosed with somatic cough syndrome, non-
pharmacologic trials of hypnosis, suggestion therapy, reassurance, counselling or a referral to a
psychologist or a psychiatrist are recommended.

A small number of studies of psychogenic cough from Germany (14), Turkey (15), Italy (16) and
Portugal (17) have been published after the systematic review and updated ACCP cough
guidelines. These papers consisted of two case studies, a case series of four children with
psychogenic cough, and a study of 563 children with all causes of chronic cough (16). In this latter
study (16), children suspected of having a psychogenic cough were diagnosed by a psychiatrist
based on a honking cough and reduction of cough when sleeping. A newly published Korean
cough guideline (18) includes psychogenic cough and describes it as unconsciously persistent
cough without an underlying diagnosis. It does not appear that ACCP cough guideline
recommendations were incorporated in these publications. It is unclear whether this is due to the
timing of submission and publication or that the authors held a different professional perspective
regarding the condition.

Psychogenic cough/somatic cough syndrome as a unique Other Section

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 phenotype

The concept of somatic cough syndrome as a unique entity may be incongruent with later
developing concepts in cough such as idiopathic cough (19,20), unexplained cough (7), cough
hypersensitivity syndrome (21,22) and laryngeal hypersensitivity (23,24). These concepts are also
used to explain cough without obvious etiology, or that persists despite medical treatment. It is
possible that, before these later concepts in chronic cough were developed, some patients with
unexplained chronic cough or cough hypersensitivity syndrome would have been labelled as
having psychogenic cough. The distinction between somatic cough syndrome (psychogenic
cough) and other phenotypes of chronic cough is not entirely clear. For example, underling
psychological issues may be contributing factors in the pathogenesis of chronic cough in some
individuals, and yet unexplained cough can exist without psychomorbidity.

Psychomorbidity in chronic cough Other Section

Psychomorbidity can be increased in patients with chronic cough. Several studies have
conducted prospective examination of psychomorbidity in chronic cough (24-27). McGarvey (25)
examined levels of psychiatric morbidity in 57 patients referred for specialist evaluation of cough.
Patients completed the Hospital Anxiety and Depression Scale (HADS) (28), the State Trait Anxiety
Index and the Crown Crisp Experiential Index. Forty two patients had successfully treated cough
and 15 had idiopathic chronic cough. Anxiety scores were in the abnormal range (>8) in 33%,
while depression scores were in the abnormal range in 16 percent. Mean anxiety and depression
scores were in the normal range. These results were similar to those found in other chronic
respiratory diseases such as chronic airflow obstruction but less severe than in those with
asthma. These results were similar to another study (26) that demonstrated mean anxiety and
depression scores (HADS) in patients with chronic cough were in the normal range, however
anxiety scores were outside the normal range in 33% of these patients. Trait anxiety, i.e.,
underlying tendency to anxiety, was moderate in 44% of patients and high in 4% (25). State
anxiety, i.e., how anxious the individual is now, was moderate in 28% of patients (25). The Crown
Crisp Experiential Index scores were elevated compared with published norms but lower than for
psychiatric outpatient populations (25). French (27) reported anxiety scores in the mild range on
the Depression, Anxiety and Stress Scale however depression and stress scores were in the
normal range. These studies demonstrate that there is increased psychomorbidity in some but not
all individuals with chronic cough.

A cross-sectional observational study of patients with a range of laryngeal hypersensitivity

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 disorders including chronic cough, paradoxical vocal fold movement, globus pharyngeus and
muscle tension dysphonia (24) examined symptoms, quantitative sensory testing, anxiety and
depression. There was no significant difference in severity of symptoms or quantitative sensory
testing results between the patient groups, however results were significantly worse than in
healthy controls. Mean anxiety and depression scores (Table 2) were in the normal range for most
patient groups, with the exception of anxiety scores in the globus pharyngeus group. There was
no significant difference in mean scores for anxiety and depression between the patient groups
and however mean scores were significantly higher than healthy controls (Table 2). There has been
no systematic assessment of laryngeal hypersensitivity in previous studies of patients with
psychogenic cough.

Table 2 Comparison of Hospital Anxiety and Depression Scale in

individuals with chronic cough, paradoxical vocal fold movement, globus
pharyngeus, muscle tension dysphonia and healthy controls (24)
Full table

There is a complex relationship between psychomorbidity and chronic cough. The term
psychogenic cough implies that psychological issues are an etiological factor in the development
of chronic cough. Alternatively, psychomorbidity may be a result of chronic cough in some
individuals. The management of chronic cough in primary care is variable and patients may
undergo extended and unsuccessful investigations and treatment trials in attempt to diagnose
and manage the symptoms (29). The protracted time taken to reach a firm diagnosis for chronic
cough can lead to psychological distress in some patients. Furthermore, the numerous physical,
social and emotional side effects to chronic cough such as avoidance of daily activities, difficulty
with interpersonal relationships, stress urinary incontinence and avoidance of talking, could
impact on psychological health (30-32).

Psychological symptoms can improve following successful treatment of chronic cough. For
example, Dicpinigaitis (33) reported positive scores on the Centre for Epidemiological Studies
Depression Scale (CES-D) in 53% of patients undergoing initial specialist evaluation for chronic
cough. The mean CES-D score fell from 18.3±13.2 to 7.4±10.4 following 3 months of medical
treatment for the cough. No antidepressant medication was used in any of the patients. This study
shows that depressive symptomatology is common in patients with chronic cough but that it
improvements following successful medical treatment. Similarly, French (27) administered the
Depression, Anxiety and Distress scales to patients at baseline, three and six months following
guideline based treatment of chronic cough. Significant improvements in depression and stress
scores occurred at three and six months. Anxiety symptoms also improved between baseline and
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 three months. The improvement in depression scores following successful treatment of chronic
cough suggests that depression, if present, may often be a side effect rather than a cause of
cough.

While psychological symptoms may be the result of chronic cough, cough and respiratory
symptoms are more common in individuals with psychological morbidity (34,35). In a population
cohort study (34) chronic cough was more common in those with psychomorbidity identified using
the General Health Questionnaire-28. The most frequently reported domains were anxiety,
insomnia, somatic symptoms, social dysfunction and severe depression. A study of 600
individuals (35) compared responses on the American Thoracic Society respiratory symptom
questionnaire (ATS-Q) to the Ilfeld psychiatric Symptom Index (PSI) scores. There was a positive
association between respiratory symptoms, including cough, phlegm, wheeze and dyspnoea, and
PSI subscales of anxiety, anger, depression and cognitive disturbance. Psychological issues can
exacerbate cough in patients with asthma, whereby cough frequency increases in situations that
patients have learned to associate with asthma rather than in ones unrelated to asthma (36).
These findings suggest that the presence of psychomorbidity does not exclude organic disease
and that psychological issues can exacerbate disease severity.

It is possible that the relationship between psychological issues and chronic cough is different
between individuals. A model proposing the complex relationship between psychological issues
and chronic cough is presented in Figure 1. This figure suggests that co-existing psychological
issues in chronic cough may a causal factor in the pathogenesis of cough, a side effect of chronic
cough, or be unrelated.

Figure 1 Three different relationships between psychological issues and

chronic cough. (A) Cough is a result of psychomorbidity; (B)
psychomorbidity is the result of cough; (C) cough and psychomorbidity
co-exist but have no causal relationship.

Clinical implications: assessment and diagnosis Other Section

Several clinical issues need to be considered in the assessment diagnosis and management of
chronic cough associated with psychomorbidity. According to the ACCP cough guidelines,
somatic cough syndrome (psychogenic cough) should only be diagnosed if the patient meets the
DSM-5 criteria. The diagnosis should not be made or excluded on the basis of nocturnal cough or
a cough with barking/honking quality (12). This raises the question of whether it is helpful to
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 diagnose somatic cough syndrome as a distinct phenotype of cough or whether it is sufficient to
recognize that patients with chronic cough, such as unexplained chronic cough or cough variant
asthma, may have increased psychomorbidity. The term somatic cough syndrome has been
recommended to replace psychogenic cough. It is unlikely that these two terms refer to different
conditions although perhaps the term somatic cough syndrome places more emphasis on
somatic symptoms and incongruity between the distress experienced by the patient and disease
severity.

It may be difficult to conceptualise how somatic cough syndrome (psychogenic cough) relates to
other types of chronic cough. The level of evidence could make it tempting to dismiss the concept
of somatic cough syndrome in favour of more recently developed paradigms such as unexplained
cough and cough hypersensitivity syndrome. While diagnosing a patient as having somatic cough
syndrome may be the subject of debate, it is helpful to recognize that psychological issues can
impact on the perception of disease severity, the development and maintenance of cough
symptoms, and upon self-management of symptoms in some individuals.

Patients presenting with chronic cough who have a history of mental health disorders pose a
diagnostic dilemma. It is often unclear whether the psychological issues have contributed to the
development of or maintenance of the cough symptoms or whether they are a separate coexisting
problem. The nature of causality in this relationship needs to be confirmed and the co-existence
of psychological issues should not be over-interpreted as being causal. The distinction may be
helpful to identify contributing causes of the cough and facilitate referral to relevant mental health
professionals.

Clinical implications: management Other Section

There is only low quality evidence to support any particular treatment approach for somatic cough
syndrome (psychogenic cough). Trials of non-pharmacological therapy such as hypnosis,
suggestion therapy, reassurance and counselling may be beneficial after adequate medical
assessment (8). The effects of treatment should be measured using recognized outcome
measures for cough (37). Referral to a psychologist or a psychiatrist is also recommended.

Some patients may resent being labelled as having a psychological disorder, and therefore
sensitive and tactful discussion of psychological issues may be needed. Routine screening of
anxiety and depression in patients with chronic cough, similar to screening for other comorbidities
such as reflux, may normalize consideration of psychological issues in this population, and help to
identify patients at risk.
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 It may be helpful to consider somatic cough syndrome (psychogenic cough) in a similar manner to
the way in which other diseases associated with cough have conceptualised. Song (38) proposed
that commonly associated conditions such as rhinosinusitis, esophinophilic bronchitis, asthma
and gastroesophageal reflux disease may not be fundamental to the etiology of cough but may
serve as triggers to the cough. Similarly, co-existing psychological issues could be viewed as
triggers or exacerbating factors for cough in susceptible individuals; however further data would
be required to test this hypothesis.

There are several strategies that may be helpful when managing a patient with suspected somatic
cough syndrome (psychogenic cough) or with cough suspected of being associated with
psychological issues. The process of assessment and clinical problem solving, particularly those
used in non-pharmacological approaches, can be therapeutic as they facilitate the patient’s
understanding of the contributing factors to their symptoms and their responses to precipitating
stimuli. Once serious and commonly-occurring diseases associated with chronic cough have
been excluded, it may be more appropriate to focus on symptom control rather than the cause of
the cough. Approaches utilizing symptom control are commonly employed in behavioural
treatments where patients are taught to identify precipitating sensations to the cough and
implement a cough suppression strategy to inhibit the cough. It may be necessary to reassure the
patient that there is no serious disease and that the cause of the cough is unable to be identified
in many patients. Approaches that focus on symptomatic treatment may be successful in
reducing coexisting psychological symptoms.

The therapeutic program should be designed to enable active participation from the patient.
Behavioural management of chronic cough involves reassurance that there is no benefit to
coughing and that the cough is safe to suppress despite a precipitating sensation. Many patients
with chronic cough view their cough as a reflex over which they have no voluntary control (27,30).
However, functional magnetic resonance imaging studies demonstrate the role of the
supramedullary pathways including the cerebral cortex during cough, and changes in brain
behaviour during active cough suppression (39), suggesting a voluntary component to cough. The
therapy process aims to teach patients to exert voluntary control over their cough behaviour.

Future research Other Section

There is little evidence to guide the definition and diagnosis of somatic cough syndrome
(psychogenic cough), and many questions about the condition remain unanswered. Further
research is needed to distinguish between somatic cough syndrome and other types of chronic
cough such as unexplained cough or cough hypersensitivity syndrome. The clinical and
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 psychiatric profile of patients who are likely to have somatic cough syndrome has not been
determined or differentiated from other forms of chronic cough. Prospective studies using
standard diagnostic criteria for both excluding coexisting disease and establishing the somatic
cough syndrome diagnosis is needed. It is unclear whether certain personality and psychiatric
conditions magnify symptom severity and reduce ability to self-manage chronic cough regardless
of whether it is classified as somatic cough syndrome.

Conclusions Other Section

Psychomorbidity is present in patients with chronic cough with a variety of etiologies, and tends
to decrease following successful treatment. Psychogenic cough may have been used in the past
as a way to explain refractory cough. Now, with more research, we might wonder whether there
are better ways to describe and deal with refractory cough such as cough hypersensitivity
syndrome. It might be more effective to consider psychological issues as a trigger or exacerbating
factor in cough until further research is conducted to accurately identify the phenotype of somatic
cough syndrome.

Acknowledgements Other Section

The author recognizes the work of the American College of Chest Physicians Guideline panel in
the development of the guidelines that have underpinned this paper. The assistance of Catherine
Banney for manuscript feedback and Mary Aldrich in the table and figure formatting is also
appreciated.

Footnote Other Section

Conflicts of Interest: The author has no conflicts of interest to declare.

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Cite this article as: Vertigan AE. Somatic cough syndrome or psychogenic cough—what is the
difference? J Thorac Dis 2017;9(3):831-838. doi: 10.21037/jtd.2017.03.119
: