- Email: [email protected]
Disabling cough: habit disorder or tic syndrome?
CORRESPONDENCE
advance medical research, but very disturbingly 12 (8%) signed the informed consent form because they feared to refuse. By comparison of these data with those gathered in the circumstances of a non-acute situation (chronic heart failure trials with ample time for consideration, deliberation, and dialogue), we were surprised to note a strikingly similar pattern of perceived patients’ understanding, no better than in the acute situation.5 Moreover, 63% (71/112) of acute and 51% (32/63) of chronic patients recalled only an oral explanation of the trial, choosing to forget written explanations. These data suggest that human nature could be a major determinant of perceived comprehension. Irrespective of urgency (and of level of education in our study), a certain and similar proportion of patients always believe they comprehend and recall very well the explanations given by the health-care team. However, many patients prefer not to be involved in medical decisionmaking, and consciously or subconsciously recollect less well the processes at the time of consent and recruitment to the trial. We support the plea for a simpler, more intelligible, and perhaps more creative approach. We might need a strategy tailored in accord with a patient’s profile, personality, and culture, and to the specific medical situation. It would be useful to establish a concerted multinational effort spearheaded by clinical-trial and ethics experts, working in collaboration with liberal and creative legal backing. *Basil S Lewis, Rita Yuval, David A Halon, Moshe Y Flugelman Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa 34362, Israel (e-mail: [email protected]) 1
2
3
4
5
Williams BF, French JK, White HD, for the HERO-2 consent substudy investigators. Informed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study. Lancet 2003; 361: 918–22. Boisjolie CR, Sharkey SW, Cannon CP, et al. Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department. Am J Cardiol 1995; 76: 396–98. De Luca SA, Korcuska LA, Oberstar BH, Rosenthal ML, Welsh PA, Topol EJ. Are we promoting true informed consent in cardiovascular clinical trials? J Cardiovasc Nurs 1995; 9: 54–61. Yuval R, Halon DA, Merdler A, et al. Patient comprehension and reaction to participating in a double-blind randomized clinical trial (ISIS-4) in acute myocardial infarction. Arch Intern Med 2000; 160: 1142–46. Yuval R, Halon DA, Flugelman MY, Lewis BS. Perceived patient comprehension in acute and chronic cardiovascular clinical trials. Cardiology 2003; 99: 68–71.
Disabling cough: habit disorder or tic syndrome?
treatment of habit cough with suggestion therapy is essential to prevent extended morbidity and inappropriate treatment for suspected organic disease.
Sir—In their Case report of a 15-yearold boy with disabling cough, Josephine Ojoo and colleagues (Feb 22, p 674)1 attribute the disorder to a tic syndrome. Despite the reported prompt clinical response to a single dose of pimozide, this case fits the pattern typical of habit cough syndrome.2 Contrary to Ojoo and co-workers’ contention that in many children “there is little need for therapy” for habit cough, this type of cough is associated with long-term morbidity if appropriate treatment is not provided.3 Although repetitive daily coughing without any cough during sleep has been variously classified as psychogenic or a tic syndrome,4 we believe that the syndrome is a habit disorder that is amenable to suggestion therapy.5 In 1966, Berman2 described six patients with this disorder who were successfully treated with therapy that “relied solely on the art of suggestion”. We used 15 min of intensive suggestion therapy in nine patients and found that this treatment resulted in immediate and sustained cessation of cough.5 Most of our patients had undergone extensive medical assessment and treatment before being seen by us. Treatment for presumed asthma was common and five of the patients had previously been admitted to hospital. Indeed, failure to initiate suggestion therapy can adversely affect patients’ outcome. Rojas and colleagues3 reported that in 44 of 60 patients with habit cough who did not receive suggestion therapy it took about 6 months after diagnosis for resolution of cough, and 16 patients continued to have symptoms for many years. Patients who present with sustained repetitive coughing without any cough during sleep are more likely to have habit cough than a tic disorder, Tourette’s syndrome, or a psychological disorder. With the classic presentation of this disorder, we routinely forego most of the extensive diagnostic tests described by Ojoo and colleagues, and progress to 15 min of suggestion therapy. Since our initial report,5 we have seen many more of these patients and continue to have the same degree of success with suggestion therapy. In most patients with this clinical pattern of cough, a careful history is sufficient to make the diagnosis. Tests of pulmonary function and a chest radiograph are generally sufficient additional assessments to assure the physician and the patient’s family that nothing has been missed. Early recognition and
Miles Weinberger
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
Department of Paediatrics, Allergy and Pulmonary Division, University of Iowa College of Medicine, University of Iowa Hospital, Iowa City, IA 52242, USA (e-mail: [email protected]) 1 2 3
4
5
Ojoo JC, Kastelik JA, Morice AH. A boy with a disabling cough. Lancet 2003; 361: 674. Berman BA. Habit cough in adolescent children. Ann Allergy 1966; 24: 43–46. Rojas AR, Sachs MI, Yunginger JW, O’Connell EJ. Childhood involuntary cough syndrome: a long-term follow-up study. Ann Allergy 1991; 66: 106. Weinberg EG. Honking, psychogenic cough tic in children. S Afr Med J 1980; 57: 198–200. Lokshin B, Lindgren S, Weinberger M, Koviach J. Outcome of habit cough in children treated with a brief session of suggestion therapy. Ann Allergy 1991; 67: 579–82.
Sir—There are important issues that Josephine Ojoo and co-workers1 do not discuss, which question the accuracy of their diagnosis of habitual cough, suggestive of a tic disorder, and the appropriateness of management with diphenylbutylpiperidine pimozide, a neuroleptic treatment for Tourette’s syndrome. Habit cough, like other non-organic persistent symptoms, has a psychosomatic origin.2 Although the typical habit cough, as described in this case, has many similarities with other childhood habits, such as hair twiddling and nail biting, it does not have the features of a Tourette-like tic. As a result of the debilitating cough, the child adopts a sick role and becomes the main focus of concern for the family. He or she then stops normal activities and withdraws from school, friendships, and hobbies. This diminished lifestyle contributes to the persistence of the cough. These children have all demands removed from them and the main expectation of others is for their physical wellbeing. The management of habit cough has several components. We believe that physical investigations are inappropriate, since they maintain the fallacy that the child is seriously ill. The child must not be made to feel that they are faking the cough. A habit is a compulsive behaviour and it takes time to give up, a child cannot be expected to simply stop it. A programme of gradual rehabilitation into normal activity needs to be initiated, with a structured weekly timetable. Techniques to help the child reduce the frequency of habit cough should also be established—for example, breathing exercises that
1991
For personal use. Only reproduce with permission from The Lancet Publishing Group.
advance medical research, but very disturbingly 12 (8%) signed the informed consent form because they feared to refuse. By comparison of these data with those gathered in the circumstances of a non-acute situation (chronic heart failure trials with ample time for consideration, deliberation, and dialogue), we were surprised to note a strikingly similar pattern of perceived patients’ understanding, no better than in the acute situation.5 Moreover, 63% (71/112) of acute and 51% (32/63) of chronic patients recalled only an oral explanation of the trial, choosing to forget written explanations. These data suggest that human nature could be a major determinant of perceived comprehension. Irrespective of urgency (and of level of education in our study), a certain and similar proportion of patients always believe they comprehend and recall very well the explanations given by the health-care team. However, many patients prefer not to be involved in medical decisionmaking, and consciously or subconsciously recollect less well the processes at the time of consent and recruitment to the trial. We support the plea for a simpler, more intelligible, and perhaps more creative approach. We might need a strategy tailored in accord with a patient’s profile, personality, and culture, and to the specific medical situation. It would be useful to establish a concerted multinational effort spearheaded by clinical-trial and ethics experts, working in collaboration with liberal and creative legal backing. *Basil S Lewis, Rita Yuval, David A Halon, Moshe Y Flugelman Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa 34362, Israel (e-mail: [email protected]) 1
2
3
4
5
Williams BF, French JK, White HD, for the HERO-2 consent substudy investigators. Informed consent during the clinical emergency of acute myocardial infarction (HERO-2 consent substudy): a prospective observational study. Lancet 2003; 361: 918–22. Boisjolie CR, Sharkey SW, Cannon CP, et al. Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department. Am J Cardiol 1995; 76: 396–98. De Luca SA, Korcuska LA, Oberstar BH, Rosenthal ML, Welsh PA, Topol EJ. Are we promoting true informed consent in cardiovascular clinical trials? J Cardiovasc Nurs 1995; 9: 54–61. Yuval R, Halon DA, Merdler A, et al. Patient comprehension and reaction to participating in a double-blind randomized clinical trial (ISIS-4) in acute myocardial infarction. Arch Intern Med 2000; 160: 1142–46. Yuval R, Halon DA, Flugelman MY, Lewis BS. Perceived patient comprehension in acute and chronic cardiovascular clinical trials. Cardiology 2003; 99: 68–71.
Disabling cough: habit disorder or tic syndrome?
treatment of habit cough with suggestion therapy is essential to prevent extended morbidity and inappropriate treatment for suspected organic disease.
Sir—In their Case report of a 15-yearold boy with disabling cough, Josephine Ojoo and colleagues (Feb 22, p 674)1 attribute the disorder to a tic syndrome. Despite the reported prompt clinical response to a single dose of pimozide, this case fits the pattern typical of habit cough syndrome.2 Contrary to Ojoo and co-workers’ contention that in many children “there is little need for therapy” for habit cough, this type of cough is associated with long-term morbidity if appropriate treatment is not provided.3 Although repetitive daily coughing without any cough during sleep has been variously classified as psychogenic or a tic syndrome,4 we believe that the syndrome is a habit disorder that is amenable to suggestion therapy.5 In 1966, Berman2 described six patients with this disorder who were successfully treated with therapy that “relied solely on the art of suggestion”. We used 15 min of intensive suggestion therapy in nine patients and found that this treatment resulted in immediate and sustained cessation of cough.5 Most of our patients had undergone extensive medical assessment and treatment before being seen by us. Treatment for presumed asthma was common and five of the patients had previously been admitted to hospital. Indeed, failure to initiate suggestion therapy can adversely affect patients’ outcome. Rojas and colleagues3 reported that in 44 of 60 patients with habit cough who did not receive suggestion therapy it took about 6 months after diagnosis for resolution of cough, and 16 patients continued to have symptoms for many years. Patients who present with sustained repetitive coughing without any cough during sleep are more likely to have habit cough than a tic disorder, Tourette’s syndrome, or a psychological disorder. With the classic presentation of this disorder, we routinely forego most of the extensive diagnostic tests described by Ojoo and colleagues, and progress to 15 min of suggestion therapy. Since our initial report,5 we have seen many more of these patients and continue to have the same degree of success with suggestion therapy. In most patients with this clinical pattern of cough, a careful history is sufficient to make the diagnosis. Tests of pulmonary function and a chest radiograph are generally sufficient additional assessments to assure the physician and the patient’s family that nothing has been missed. Early recognition and
Miles Weinberger
THE LANCET • Vol 361 • June 7, 2003 • www.thelancet.com
Department of Paediatrics, Allergy and Pulmonary Division, University of Iowa College of Medicine, University of Iowa Hospital, Iowa City, IA 52242, USA (e-mail: [email protected]) 1 2 3
4
5
Ojoo JC, Kastelik JA, Morice AH. A boy with a disabling cough. Lancet 2003; 361: 674. Berman BA. Habit cough in adolescent children. Ann Allergy 1966; 24: 43–46. Rojas AR, Sachs MI, Yunginger JW, O’Connell EJ. Childhood involuntary cough syndrome: a long-term follow-up study. Ann Allergy 1991; 66: 106. Weinberg EG. Honking, psychogenic cough tic in children. S Afr Med J 1980; 57: 198–200. Lokshin B, Lindgren S, Weinberger M, Koviach J. Outcome of habit cough in children treated with a brief session of suggestion therapy. Ann Allergy 1991; 67: 579–82.
Sir—There are important issues that Josephine Ojoo and co-workers1 do not discuss, which question the accuracy of their diagnosis of habitual cough, suggestive of a tic disorder, and the appropriateness of management with diphenylbutylpiperidine pimozide, a neuroleptic treatment for Tourette’s syndrome. Habit cough, like other non-organic persistent symptoms, has a psychosomatic origin.2 Although the typical habit cough, as described in this case, has many similarities with other childhood habits, such as hair twiddling and nail biting, it does not have the features of a Tourette-like tic. As a result of the debilitating cough, the child adopts a sick role and becomes the main focus of concern for the family. He or she then stops normal activities and withdraws from school, friendships, and hobbies. This diminished lifestyle contributes to the persistence of the cough. These children have all demands removed from them and the main expectation of others is for their physical wellbeing. The management of habit cough has several components. We believe that physical investigations are inappropriate, since they maintain the fallacy that the child is seriously ill. The child must not be made to feel that they are faking the cough. A habit is a compulsive behaviour and it takes time to give up, a child cannot be expected to simply stop it. A programme of gradual rehabilitation into normal activity needs to be initiated, with a structured weekly timetable. Techniques to help the child reduce the frequency of habit cough should also be established—for example, breathing exercises that
1991
For personal use. Only reproduce with permission from The Lancet Publishing Group.