Psychogenic cough is a rare cause of chronic cough in adults. It is typically persistent, disrupts daily activities and causes long-term morbidity. In contrast with cough of organic etiology, there is no clinical or laboratory evidence of disease.1,2

Efforts to make an early diagnosis will reduce morbidity, prevent fixation of symptoms and avoid unnecessary procedures and therapies.2

We report the case of a 45-year-old woman, Caucasian, non-smoker, no habitual medication and no known previous allergies.

The patient consulted her family doctor due to a 9-week history of coughing fits.

The cough started and persisted after an upper respiratory tract infection treated with antibiotics (amoxicillin/clavulanic acid) and antihistamine (hydroxyzine). It was described as violent, nonproductive, occurring every few minutes, disrupting speech, work and daily activities, but not sleep because it disappeared at night.

Physical examination, including ear, nose and throat evaluation was normal, and no noticeable motor tic was observed.

No organic etiology was detected on medical examinations, including chest and sinus X-rays, skin-prick test for allergies, spirometry with bronchial challenge, thyroid ultrasound and chest computed tomography.

Pharmacological therapy with antihistaminic/decongestant (pseudoephedrine+triprolidine), inhaled corticosteroid (budesonide) and bronchodilator (salbutamol) was ineffective. A trial of acid suppression (omeprazole), prokinetic (metoclopramide) and dietary modification also failed.

During investigation, regular consultations were scheduled. In the course of these consultations, she reported depressive symptoms. She related them to work-related distress, which began 2 months before the coughing fits, when she was moved to a new position. We perceived that cough was always present except when she spoke about her work-related distress. This observation, in association with negative findings on diagnostic tests, lack of response to therapy and the clinical characteristics of the cough, raised the suspicion of a psychogenic etiology.

A plan of weekly cognitive psychotherapy, in addition to antidepressant therapy with sertraline, was initiated. After five weeks, the cough disappeared and depressive symptoms decreased. No relapses were reported in the following twelve months.

In adult patients with chronic cough, doctors should always work toward a clear diagnosis, considering common and rare illnesses.3

Little has been published on diagnostic approaches.1,4 However, when extensive evaluation and therapy fail to detect an organic cause, psychogenic cough should be considered.1,3,5 Upper respiratory infections, depressive disorders and work distress have been described as precipitating factors.3,5 In this case, a psychogenic origin was first suggested by cough absence during sleep and while speaking about work distress.1,4

Non-pharmacological therapies have been reported to be more effective than pharmacological treatments.3 However, there is a lack of randomized, controlled studies comparing different strategies.2

This case highlights the role of an empathic and integrated approach by the family doctor. It made early diagnosis possible, and non-pharmacological and pharmacological treatments could be started immediately, thus avoiding specialist referral and iatrogenic complications.

In conclusion, psychogenic cough is a rare entity, diagnosed after extensive exclusion of organic causes, positive clinical findings and response to specific therapy.