The
Cough
and the Bedsheet
Sidney
0. Cohlan,
MD, and
Shirley
M. Stone,
MD
From the Department of Pediatrics, New York University Medical Center, New York
ABSTRACT. Of 33 patients with psychogenic cough tic,
31 were successfully treated using an unusual reinforced suggestion technique. The cough usually follows an
mci-dental 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 diag-nostic procedures and therapy. Thirty percent of some 20
patients previously reported in the literature had been hospitalized. The reinforced suggestion technique de-pends 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
will-ingly 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 psy-chogenic etiology. Early recognition of the nonorganic nature of this syndrome will reduce parental anxiety, loss of school time, risk of iatrogenic complications, and
un-necessary medical and hospital expense. Pediatrics 1984;74:11-15; cough paroxysms, upper respiratory tract infection, psychogenic cough tic syndrome.
associated cough. The respiratory symptoms sub-side but the cough persists and has been variously described as barking, brassy, explosive, or croupy. The cough is very loud, and it occurs as recurrent paroxysms every five to ten minutes (or even more frequently), ceasing with sleep and lasting any-where from 3 weeks to 6 months. Most of the children are denied school attendance because of the continuous disturbing noise in the classroom. The British’ have likened it to the call or “honking” of the Canadian wild goose and refer to the children
as “honkers.”
Although the syndrome is more prevalent than realized, there have been relatively few articles in the literature; approximately 20 patients have been described. In most of these, as well as in the 33 patients reported here, the condition continued un-recognized for a period of weeks to months, and in the course of management there was increasing parental anxiety, loss of school time, risk of iatro-genic complications, and unnecessary medical and hospital expense.
By chance we discovered an unusual form of reinforcement suggestion therapy which was suc-cessful in curing 31 of 33 patients. We will describe
this “bedsheet” technique in a typical case report.
CASE REPORT
Over the past 25 years we have successfully treated 31 of 33 patients with psychogenic cough tic syndrome. This syndrome usually follows an insignificant upper respiratory tract infection with
Received for publication May 28, 1983; accepted Oct 4, 1983. This paper was presented, in part, before the Eighth Annual
Pediatric Alumni Day of the Department of Pediatrics, New York University Medical Center, June 25, 1982.
Reprint requests to (S.Q.C.) Department of Pediatrics, New York University Medical Center, 530 First Aye, New York, NY 10016.
PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the American Academy of Pediatrics.
B.Z., a 9-year-old white boy, was seen in consultation with a chief complaint of paroxysms of a loud, hoarse,
honking cough of 6 weeks duration. He had a mild upper respiratory tract infection with cough at the onset. The
upper respiratory symptoms subsided, but the cough per-sisted and grew in intensity and frequency. Paroxysms occurred every few minutes during the day and ceased
only during sleep at night. He was a good student and
enjoyed school, but his class could not tolerate the
inces-sent noise of his cough and he was asked to stay home
consid-ered. The patient had been treated with a variety of
antihistamines, decongestants, expectorants, cough
sup-pressants, bronchodilators, antibiotics, and steroids, to
no avail. The patient’s past history was unremarkable. During the history taking the patient sat with an
unconcerned attitude and a cynical smile which was interrupted at frequent intervals by paroxysms of
cough-ing that did not appear to disturb him. During a quiet
interval, when asked to “let me hear you cough again,”
he burst out into a typical paroxysm, without a change in facial expression. At this time he was told that his troubles were over, that we knew exactly what his prob-lem was and exactly how to cure it. He responded with a typical look of careless disbelief followed by an aborted laugh. He was then examined. The lungs were clear and
there were no other abnormal findings except an absent
gag reflex and a diminished cornea! reflex.
After the physical examination, the patient was told
that his constant paroxysms had weakened his chest muscles, which were therefore no longer able to contain his coughing, and that a bedsheet, which had been
brought in at that moment, would be tied around his
chest to serve as added support for the muscles. With this support, the muscles would then be able to suppress
his cough. The sheet was folded longitudinally, wrapped around his back and as it was tightly tied in a double knot over his sternum a command of “no more cough” was given. The patient typically complained that the sheet was too tight and made a weak attempt to cough; this was met by another sharp command to “stop it.” The
child was then told that if he felt an urge to cough that he was to breathe in and out through his mouth. The parent and child were instructed that the sheet was to be worn at all times, including sleep, and that he was to go to school the next day wearing the sheet, unless he was sure he would no longer cough when it was removed.
Following the abortive cough as the sheet was being applied, there were no further coughing paroxysms. The child was told to put his clothes on over the sheet and was escorted to the waiting room while the diagnosis and unconventional treatment was explained to the mother.
DISCUSSION
Awareness and early diagnosis is the key to the management of cough tic. As is always the case when considering a psychogenic etiology, the phy-sician is obligated to rule out all potential organic possibilities. Many of the patients in this report had been through a multitude of escalating proce-dures: hospital work-up, seven patients; allergy testing, 21 patients; indirect laryngoscopy, 15 pa-tients; bronchoscopy, five patients; lung scan, three patients; computed tomography lung scan, four pa-tients; and bone marrow aspiration, two patients.
When confronted with a long history of a chronic cough without any other signs of acute or chronic illness and negative findings on preliminary labo-ratory screening (complete blood count, tuberculin testing, chest roentgenogram), a nonorganic
etiol-ogy should be suspected. The identifying features
(Table 1) in the typical patient support the poten-tial of a psychogenic etiology. The cough, once heard, is easily recognizable. It is a barking, brassy, foghorn, honking sound which penetrates walls. It occurs in paroxysms every few seconds or minutes and produces consternation in other mothers in the waiting room while the patient’s mother winces with each sound. The cougher, however, shows little
or no evidence of pain or discomfort. There is almost a “Mona Lisa” smile during the intervals between coughs, and an attitude best described as “la belle indifference.” In the examining room, the child-with no effort or sign of discomfort-can produce a full paroxysm on command. When told that we have seen his problem before, know exactly what it is, and know exactly how to cure it, the patient usually reacts with an ambivalent facial expression. He cooperates eagerly with the mechan-ics of the physical examination. The response to testing of the gag and corneal reflex can often give good supportive evidence of the nonorganic nature ofthe symptom. A majority ofpatients (20/31) have an absent-to-depressed (11/31) gag reflex. A tongue depressor can be inserted far back in the posterior pharynx, often reaching the cerivcal spine, without any gag reaction or at most a mild retching sound. The corneal reflexes are depressed (16/33) to absent (6/33). Although there is no good explanation for
this correlation, abnormal gag and corneal reflexes have long been associated with conversion hysteria symptoms. The history usually reveals an absence from school ranging from weeks to months. Some of these children are superior students. The school phobia, may be secondary. After a long absence from school, the child fears that he or she will not be able to catch up.
The use of the bedsheet technique resulted from an observation made 25 years ago of a 12-year-old child who had been honking for 6 months following
TABLE 1. Psychogenic Cough Tic Syndrome:
Associ-ated Features in 31 Patients
1. Recurrent paroxysms of barking, brassy, foghorn, honking cough every few minutes which stops only during sleep
2. Noise of cough too distracting to allow attendance at school
3. Patient can produce cough on command
4. Appears unconcerned about symptoms (la belle in-difference)
5. No objective, radiologic, or other laboratory evi-dence of disease
6. Submits willingly to procedures
7. Ambivalent to prospect of cure
recovery from measles. He was out of school and was exposed to a variety of diagnostic and thera-peutic procedures available at that time. An intern-ist who saw the child one night thought the parox-ysms of coughing were reminiscent of those he had heard during an outbreak of pleurodynia during his army experience. An accepted treatment then was tight strapping of the chest. Having no tape with him at the moment, he improvised by tying up the child’s chest with a folded bedsheet. The cough stopped instantly. The child was then hospitalized at which time he was seen by us. The bedsheet with its huge knot protruding from the chest seemed inappropriate. However, as it was loosened to be removed, the patient had an immediate paroxysm of a honking, barking cough with circumoral cy-anosis. The sheet was quickly retied and the par-oxysm abruptly stopped. This child also had a spu-rious dystonic gait. He required psychiatric man-agement reluctantly agreed to by the parents.
Several months later, we saw in consultation a 7-year-old child with a 4-month history of continuous coughing. The sound was reminiscent of that heard in the previous case. There had been a complete work-up including bronchoscopy and bronchogra-phy without any evidence of disease. Findings from the physical examination at this time were normal. We could think of nothing else to add and decided to try the bedsheet. The cough ceased immediately.
The success of this reinforced suggestion tech-nique depends, to a large extent, on impressing the patient that the physician knows exactly how to cure the symptoms, on the physician’s seriousness and confidence in his success, and in not informing the parents beforehand of what is to occur.
The parents’ reaction to the “performance” is usually one of wide-eyed incredulity. It is essential at this point to explain to the parents that what they had witnessed was a form of reinforced sug-gestion. They must be carefully informed and com-pletely understand that the symptom was psycho-somatic; that the child was not faking or doing it on purpose; that it was a form of tic, like eye blinking; and that the child had no control over it. They are also told not to mention this conversation to the child and if the cough stops and the child returns to school without incident that no further therapy is usually indicated. During the conversa-tion, we try to explain to the parents that part of the technique depends upon the fact that after coughing for so many months we have now given the child an explanation for his symptoms and a device to help him stop. It would be very difficult after coughing for so long for him to wake up one morning and declare that the cough had disap-peared. He needed a way out, a face-saving
mech-anism. An attempt is then made to explore with them what recent events, pressures, or interfamily relationships might have contributed to this psy-chosomatic incident. If any probable causative fac-tors emerge, advice and counseling are given. They are advised to return if the cough resumes or if any
other unusual behavioral symptoms occur, at which time psychiatric consultation may be indicated.
Because of her age and her response, a patient
seen 2 years ago merits discussion. The patient was
a 5-year-old girl with an uneventful past history, who, following an unremarkable upper respiratory tract infection, persisted with a barking, brassy cough, during the daytime only, for a period of 6 weeks. Laboratory work-up included a computed tomography scan of the chest which showed no apparent disease. Findings from physical exami-nation were entirely unrewarding. We had nothing else to offer except reinforced suggestion. The child was obviously too small for a bedsheet, so a roll of 2-in ace bandage was applied with enough pressure to induce moderate pain. She was then told that the bandage had to remain until she stopped cough-ing. She was escorted out of the examining room but returned after five minutes and said, “Doctor, I learned how to make this cough and I can unlearn
it too.” The bandage was removed and the child hasn’t had any further symptoms. This girl is the youngest patient in this series or in the literature to exhibit a psychogenic cough tic.
One of the earliest reports in the review of the scant literature on this subject is by Bernstein.2 His 1963 article, “A Respiratory Tic: A Barking Cough of Puberty,” reported a 12-year-old girl with a
a button apparently works as well as a bedsheet. There have been a total of 20 patients with psychogenic cough tic reported; six of these patients were hospitalized. Berman3 reported six children, aged 9 to 13 years, all of whom responded to coun-seling and suggestion after several days to weeks. Kravitz et a14 documented nine cases of psychogenic cough tic. One child stopped coughing following
bronchoscopy after having been told that this was a curative procedure. One child required 8 months
of psychiatric hospitalization; other patients also responded as did most of the reported patients to
suggestion and counseling over varying periods of time (days to weeks). The three patients reported by Weinberg’ were all hospitalized and all re-sponded similarly. Lorin et a15 reported a case of multiple rib fracture which resulted from 1 1 weeks of a psychogenic cough, thus demonstrating the severity and forcefulness of the paroxysms. After
several days of explanation and suggestion the cough stopped. A 7-year follow-up of this patient revealed no cough recurrence or other psychogenic
symptoms. Our follow-up on 31 patients has been
meager due to family mobility (Table 2). One-year follow-up on ten patients and a 2-year follow-up on six patients revealed no further psychogenic
symp-toms. One patient observed over a 20-year period
has had recurrent episodes of a variety of
conver-sion symptoms; this patient has required psychiat-nc management. Another patient from our practice, whom we have known since birth, had an episode at age 14 years. She had no further psychosomatic
symptoms (she is now a healthy woman whose three children are under our care). A more intense effort at follow-up of these children might have afforded relevant data on the relationship, if any, between cough tic episodes and future psychogenic manifes-tations. Our impression is that most of these
chil-TABLE 2. Clinical Data and Follow-up on 33 Patients with Psychogenic Cough Tic
Patient No.
Sex Age (yr)
Duration of
Symptoms
(wk)
Previous
Diagnostic
Procedures*
Previous
Therapyt
“Bedsheet”
Cough
Control
Follow Months
-up
Years
1 M 12 24 1, 2, 8 a, b Yes ...
2 M 7 16 1, 2, 7, 8 a, b, d Yes 26
3 F 11 4 1 a,b Yes ...
4 F 8 11 2 a,b Yes 12
5 F 12 4 1,2,3,7,8 a,b,d,e Yes 14
6 F 11 7 1,2 a,b,c No 21
7 M 9 6 2,3 a,b Yes 11
8 F 14 3 a,b Yes 19
9 M 7 3 1,2,3 a,b,c,d,e Yes ...
10 F 12 5 2, 3, 6 a, b, c, d Yes 22
11 M 11 4 1, 2 a, b Yes 23
12 F 10 4 1 a,b Yes ...
13 F 10 6 1, 2 a, b, c, d, e Yes 11
14 F 8 3 1,2 a,b,c,d,e Yes 10
15 F 11 2 2, 3 a, b Yes 23
16 M 7 4 1,2,3 a,b Yes ...
17 M 9 3 1,2,3,6,7,8 a,b,c,d,e Yes 13
18 F 7 3 2 a,b,c Yes ...
19 M 8 5 2 a,b Yes 13
20 M 11 4 1, 3, 4, 5, 8 a, b Yes ...
21 F 13 11 1,2,3 a,b,c,e Yes 27
22 F 10 8 2, 3, 5,7, 8 a, b, c Yes ...
23 F 8 5 1, 3 a, b, c Yes 10
24 M 8 3 1, 3, 4 a, b, c, d, e Yes ...
25 F 9 6 1,3 Yes ...
26 F 12 4 1, 3 a, b Yes 13
27 F 9 6 1, 3, 4, 5, 7, 8 a, b, c, e Yes 14
28 M 9 3 1 a,b Yes ...
29 F 11 13 1, 3 a, b, c, e Yes 22
30 F 5 6 1, 2, 5 a, b Yes ...
31 M 14 10 1 a, b, c No ...
32 F 7 3 1,2 a,b Yes ...
33 M 9 6 1, 2 a, b, e Yes ...
* Procedures are as follows: 1, complete blood count and chest roentgenogram; 2, allergy
testing; 3, indirect laryngoscopy; 4, lung scan; 5, computed tomography chest scan; 6, bone marrow aspiration; 7, bronchoscopy; 8, hospitalization.
dren have isolated cough tic incidents.
There are probably many more children with psychogenic cough that is undiagnosed; such chil-dren are exposed to a variety of diagnostic proce-dures and therapies, not all of them without risk. Thirty percent of the patients reported in the lit-erature were hospitalized before the psychogenic etiology became evident. The purpose of this report is to alert physicians to this entity, to describe an unusual but immediately successful reinforcement suggestion technique, and to review the experience of others in an effort to prevent unneccesary and prolonged medical diagnostic procedures in chil-then and adolescents with psychogenic cough tic.
POSTSCRIPT
The following day or two after cessation of cough, approximately 20% of the patients announce their cures either by calling on the telephone or writing a letter such as the one which follows:
Dear Doctor Stone,
Thank you very much. I am so glad that my cough
stopped. When my grandmother called I said you were a magician. Well that’s what I think. Everybody is happy that you stopped my cough. When we got home I called my Doctor and told him he should take a few lessons from you to learn how to stop the cough and he said he would like to. Tonight I am going to take the sheet off. I will try to see you again soon, I hope. Oh yes, I have a suggestion. When somebody has the same cough (which I hope not) maybe they could leave their undershirt on because the sheet hurts my skin. Write soon and thank
you again. Oh! and thank the other doctors too.
REFERENCES
Love,
Rachel
1. Weinberg EG: “Honking”: Psychogenic cough tic in
chil-then. S Afr Med J 1980;57:198-200
2. Bernstein L: A respiratory tic: The barking cough of puberty.
Laryngoscope 1963;13:315-319
3. Berman BA: Habit cough in adolescent children. Ann Allergy
1966;24:43-46
4. Kravitz H, Gomberg RM, Burnstine RC, et al: Psychogenic cough tic in children and adolescents. Clin Pediatr
1969;8:580-583
5. Lorin MI, Slovis TL, Haller SO: Fracture of ribs in psycho-genic cough. NY State J Med 1978;78:2078-2079
CRUEL
WORLD
To take a child into hospital and cure his disease only to send him back to precisely those conditions which produced the disease is a form of hypocrisy as well as being no sort of economy.
Submitted by Student
