Nonorganic Cough (Differential Diagnosis and Management)

Nonorganic cough is a persistent, disruptive cough that is behavioral in nature and may be associated with secondary gain. This type of cough is often stereotypical and predictable in its manifestations and is most commonly seen in young women.

Key Features of Nonorganic Cough

Stereotyped Pattern

The cough follows a consistent, repetitive pattern throughout the consultation (e.g., “…cough…cough…COUGH” ….pause… “cough…cough…COUGH”). By contrast, while sensory neuropathic cough may involve stereotyped sensations, each coughing episode can vary in pattern, duration, and severity, often with at least occasional episodes being violent.

Distractibility

The cough tends to diminish or disappear when the patient is deeply engaged in an activity or during sleep, only to reappear upon awakening.

La Belle Indifference

Patients may display a peculiar nonchalance regarding their cough. Despite its disruptive impact—such as missed school days, disability, or relational disturbances—their emotional response is often surprisingly calm, sometimes with their demeanor conveying a subtle “Mona Lisa” quality.

Secondary Gain:

The cough may serve a functional purpose, such as drawing attention. For example, exacerbations might be a “tool” used to avoid tests or other anxiety-provoking events, or the cough might become the focal point of family dynamics, consuming significant time, energy, and resources.

Differential Diagnosis (often pursued elsewhere)

The diagnosis is typically made on a prima facie basis by physicians with strong observational skills, rather than by objective measurement or as a diagnosis of exclusion.

The Usual (Incorrect) Suspects

Allergy

If allergies are the cause, other symptoms such as a runny nose, sneezing, or itchy eyes are usually present. Furthermore, an antihistamine trial should provide relief.

Acid Reflux

Patients might experience occasional heartburn, acid brash, or similar symptoms. The cough is often worse at night and in the early morning due to nocturnal reflux and resulting irritation. And of course, a trial of a proton pump inhibitor (e.g., omeprazole) or an H2 blocker (e.g., famotidine) should improve symptoms.

Asthma

A family history of asthma may be present, and supportive evidence can be obtained from pulmonary function tests or flow-volume loops. If truly the cause of the cough, a trial of asthma treatments such as albuterol or a steroid inhaler should result in improvement.

A Real Contender to Put Aside: Sensory Neuropathic Cough:

Patients typically report a sudden, localized sensation (a tickle, dry patch, pinprick, or dripping sensation) that initiates the cough. There may be identifiable triggers—such as a loud laugh, breathing in cold air, change of position such as when lying down at night, touching a specific spot on the neck, or swallowing—that precipitate coughing episodes. A trial of neuralgia medications like amitriptyline or gabapentin often helps.

Management of Nonorganic Cough

Clinicians must recognize that nonorganic cough is often misunderstood or inadequately managed by those who rely solely on measurements and testing. Not every physician will be good at (or even be interested in being good at) managing this disorder.

A successful approach depends on strong observational and relational skills within an often-time-consuming visit. 

Even though the diagnosis is usually made on a prima facie basis, many patients have already undergone extensive evaluations to rule out the “usual suspects” mentioned above. Once nonorganic coughing is diagnosed, the basic steps of management include:

Affirm What the Disorder Is Not

Clearly dismiss/ set aside the mis-diagnoses of infection, allergy, reflux, asthma, and other organic causes.

Explain the Nature of the Disorder—What it Is

Clarify that the problem is not with the cough mechanism itself but in the way coughing is being activated behaviorally. “The disorder is not in the mechanism but in the use of the mechanism.

Establish Authority

Validate the patient’s experience by noting, “You are in good company with many other patients with this condition.” It may also be helpful to add, “I am a physician who finds it easy to say “I don’t know,” or “I am not sure, but this is a diagnosis I am certain of.”

Set Expectations for Rapid Improvement

Inform the patient that this condition typically resolves quickly with appropriate behavioral intervention.

Emphasize Behavioral Training

Explain that the solution lies not in medication but in teaching or training. You might say, “We can help you find the solution within yourself.” If available, convey to the care of a speech pathologist experienced in nonorganic disorders, with a “not more than 2 visits” stipulation to avoid subtle formation of co-dependency between patient and speech pathologist.

Utilize Positive and Negative Practice

The clinician (or a speech pathologist) may mimic the patient’s cough and then pause, asking the patient to reproduce the pattern. This exercise can subtly reinforce the behavioral nature of the cough.

Educate Caregivers

Advise parents or significant others (including primary and other physicians) that further medicalization may obscure the true nature of the disorder and hinder progress. Their job is to ignore the behavior if it persists.

Follow Up and Reassure If the Coughing Continues More Than Two Weeks

Revisit the diagnosis, address any objections, and provide reassurance as necessary.

Reaffirm the Diagnosis if Needed

If the patient does not respond as expected or if family dynamics interfere, reaffirm the diagnosis, share examples of similar cases and how they resolved, and review the concepts of “primary loss” (the cough) and “secondary gain” (the benefits the “primary loss” provides, such as attention or avoidance of responsibilities).

This comprehensive approach, relying on careful observation, clear communication, and behavioral intervention, is essential for effectively managing nonorganic cough.