Case 1 Presentation
Background. Case 1 lived in Government housing with her youth aged child. They were facing eviction due to a state of squalor characterized by vermin, disrepair, unkempt premises, fire risk to neighbors, and health hazards imposed from food waste and soiled furniture. The patient’s possessions were unorganized throughout the domicile and yard, with one exception being the youth age child’s room. The patient collected items either because she thought they were valuable and/or usable in the future or for their sentimental value (reminders of a deceased family member). The onset of HD proximal to the death of a family member is consistent with trauma and grief etiology. There was no evidence of intrusive, repetitive, or ego-dystonic thoughts that are characteristic of OCD. For Case 1 the CBT intervention targeted excessive acquisition, focused sorting strategies (rubbish, recycle, donate, sell) and grief and loss (18 sessions, delivered every two weeks at the domicile) [11].
Barriers and modifications. Barriers to sorting tasks included poor self-management of HF and diabetes resulting in high fatigability and poor adherence to between-session homework tasks, further complicated by HF and diabetes hospitalizations necessitating digit amputation. Related barriers included difficulties with ambulation compounded by the state of clutter. Safety issues were also evident including soiled furniture and hazardous medical waste (e.g. used diabetic syringes). The patient received assistance from community support services and during CBT it became evident that community support workers were abetting acquisition behaviors.
In this treatment, the patient was responsible for all sorting and discarding tasks in line with the recommendations of Steketee and Frost [11], which was facilitated by the following modifications. Firstly, the patient was referred to an occupational therapist for assistance with ambulation (i.e. mobility walking frame). Secondly, the delivery of CBT required pacing or interspersing sorting/discarding tasks in between cognitive-restructuring within sessions to compensate for high fatigability (cardiac nurse recommendation). Thirdly, during early CBT sessions, significant patient dizziness was observed resulting in premature ending of sorting/discarding tasks. It was hypothesized that postural changes (e.g. retrieving items on the floor) led to postural hypotension and transient hypoperfusion. Alternatively, dizziness may have been a hemodynamic side-effect of active diuresis or functional decline from recent hospitalization for decompensation. Thus, subsequent sessions utilized a raised platform for sorting/discarding tasks (i.e. temporary folding table) to reduce risk for serious adverse events including syncope and falls (cardiologist and occupational therapist recommendation). Finally, other modifications included extending the time length of each individual session (90-120 mins), an extended focus on exposure to discarding, and a reduction in the use of written materials and rating scales because of poor reading comprehension.