Indian Pediatrics 2004; 41:503-508 

From the Department of Psychiatry ,University College of Medical Sciences & Guru Teg Bahadur Hospital, Dilshad Garden, Delhi 110095, and *Joy Nursing Home, Rajouri Garden, New Delhi-110027, India.

Correspondence to: Professor M.S. Bhatia , Head, Department of Psychiatry, University College of Medical Sciences, Dilshad Garden, Delhi 110 095, India.
E-mail: [email protected]

Manuscript received: August 26, 2003; Initial review completed: September 29, 2003;
Revision accepted: October 29, 2003

 

Abstract:

Sneezing is usually the physiologic response to nasal irritation but intractable paroxysmal sneezing is very uncommon. Majority of cases of intractable sneezing are reported among adolescents and are psychogenic in origin. We report two adolescent girls with intractable paroxysmal sneezing in whom the removal of psychogenic stressors resulted in complete remission.

Key words: Intractable sneezing, Psychogenic factors.

Introduction

Sneezing or sternuation is a common symptom but intractable paroxysmal sneezing is very uncommon. Intractable paroxysmal sneezing is a clinical entity that was initially described in 1949(1). Since then about 40 cases have been reported, mainly among adolescents and children and of these, majority were psychogenic in origin. The common features of intractable sneezing are: (i) It is more common in adolescents and females appear to be affected more often than males(2); (ii) the individuals do not sneeze while asleep and they sneeze with their eyes open(3); (iii)generally the sneezing is refractory to a wide variety of medications but respond well to psychological measures such as psychotherapy, biofeedback, relaxation exercises and hypnosis(4,5) whereas the organic sneezing respond to topical nasal anesthesia(6,7); (iv) the psychogenic sneezing consists of an "aborted" or pseudosneeze and generally has little or no inspiratory phase, short nasal grunting and little or no aerosolization of the nasal mucous secretions; (v) one can often, but not always, elicit a significant psychiatric history(2,3,6); and finally, (vi) despite the continuous sneezing, the physical examination and relevant investigations are normal(6,7).

In addition to psychogenic origin of sneezing, it can originate due to allergic(8), infectious or local nasal cause(8,9), central nervous system (epilepsy)(8), vasomotor causes or tubercular cervical adenitis(7,8), triethanolamine sensitivity(8) or multi-factorial causation(10).

We report two adolescent girls with intractable psychogenic sneezing who remitted with psychological interventions.

Case Reports

Case 1

A 16-year-old girl studying in class XI was brought by her mother for complaints of continuous sneezing and heaviness in head for last two days. The patient was normal about two days back when she suddenly started having sneezing and heaviness of head. There was no associated nasal discharge, lacrimation or cough. The sneezing was continuous but did not occur while talking or during sleep. There was no past history of allergy, breathlessness or skin eruptions. Before being referred for psychiatric evaluation, the patient was given a trial of antihistaminics, steroids and bronchodilators but without any improvement. Local nasal examination, sinuscopy, X-ray nasal sinuses and CT scan head were normal. The child was referred for psychological evaluation. All the medications were gradually tapered off and on detailed psychological evaluation in two sessions, it was found that the patient had seen the similar episodes in one of her classmates. The patient was given special attention by the teachers in the school as well as by the family members. The pressure of performance in the examinations had also lessened as due to illness she was often missing the school and the parents had also stopped expecting excellent result in the examinations.The child was started on alprazolam at a dose of 1mg daily in divided doses and was given suggestion, distraction and explanation of the nature of symptoms. The mother was also counselled about the nature of illness, its onset and perpetuation. There was a gradual fall in the frequency of sneezing followed by complete remission. On following her up for another month, she did not develop the sneezing.

Case 2

A 16-year-old girl studying in class XII was brought by her brother for complaints of continuous sneezing, headache and dizziness. The patient was normal about five days back when she suddenly started having dizziness, episodes of sneezing and headache. There was no associated nasal discharge, lacrimation, cough or fainting. The sneezing was continuous for four to five hours but did not occur while talking or during sleep. There was no past history of allergy, breathlessness or skin eruptions. Before being referred for psychiatric evaluation, the patient was given a trial of antihistaminics and nasal decongestants but without any improvement. Local nasal examination, sinuscopy, X-ray nasal sinuses, EEG and CT scan head were normal. The child was referred for psychiatric evaluation and treatment. All the medications were gradually tapered off and on detailed psychological evaluation, it was found that the patient had been attached to her cousin sister who got recently married out of caste and hence was socially boycotted by the family. One of her close friend had also separated due to shifting of her house. Due to her illness, the patient was given a special attention by the teachers in the school as well as by her parents. The pressure of studies had also lessened as due to illness as she was often missing the school. The child was given suggestion and explanation about the nature of symptoms. The parents were also counselled about the nature of illness, its onset and perpetuation. There was a gradual fall in the duration of sneezing and headache followed by complete remission. On following her up for two months, she did not develop the sneezing.

Discussion

Both the cases matched the criteria of intractable paroxysmal sneezing. The examination and investigations were normal. In both the cases, psychogenic stressors were recognized and once the psychogenic nature of symptoms, their onset (due to underlying stress) and their perpetuation (due to secondary gain or attention from parents or teachers) were explained initially to the parents and later on to the patients, there was an improvement followed by remission of sneezing. The role of anxiolytic drugs lies in reducing underlying anxiety and making the patient more amenable to psychotherapy. There is role of supportive psychotherapy (i.e., explanation of nature of illness, suggestion to overcome symptoms) and behavior therapy (reward when there is symptom reduction, aversion therapy, hypnosis and relaxation)(4,5)

It must be emphasized that most of the reported cases of intractable sneezing are psychogenic in nature, particularly in adolescent patients(2-5,7-10). The diagnosis therefore must be considered when confronting such patients in order to avoid an unnecessary extensive medical evaluation and unneeded medications, parental anxiety and effect on school performance(2,4,7,9). Discovery of the specific psychogenic triggering event and avoidance of secondary gain (or attention) can sometime ameliorate the symptoms(5,10).

Contributors: MK, SS, GSIL worked up the cases; MSB diagnosed, reviewed the manuscript and will act as gauranter of the paper..

Funding: None.

Competing interests: None stated.