BACKGROUND
Hoarding disorder (HD) poses unique challenges to health clinicians, community services, and health regulators alike [1]. This disorder is characterized by accumulation of possessions due to excessive acquisition of, or difficulty discarding possessions, resulting in clutter severe enough to cause emotional distress, impair functioning, and preclude the use of living spaces for their intended purposes [2]. The addition of HD to international psychiatric classification systems, distinct from obsessive-compulsive disorder (OCD), underscores the importance and topical nature of this complex disorder [3].
Emerging evidence indicates the importance of HD to cardiovascular health. Specifically, the prevalence of heart disease is significantly higher in populations with HD than those without this disorder [4]. Autopsy of 61 unexplained deaths in persons with HD indicated that heart disease accounted for 50% of sudden deaths [5], with severe coronary artery stenosis (42.4%) and myocardial replacement fibrosis (44.1%) common. Moreover, an in-vivo observational study during cognitive-behavioral therapy (CBT) showed that patients with HD demonstrated increased cardiovascular response when discarding personal possessions versus control items [6].
Cognitive-behavioral therapy is a frontline treatment for individuals with HD. A recent meta-analysis demonstrated that large effect sizes were seen on HD severity (g = 0.82) [8]. Contemporary CBT for HD focuses heavily on within-session and between-session sorting and discarding [9]. Other components of treatment often include skills training relevant to decision making and problem solving, motivational enhancement, emotional regulation training, cognitive change techniques, and reducing acquisition [9].
To the best of the authors’ knowledge, no prior research has described the presenting psychiatric and cardiovascular characteristics, nor illustrated the therapeutic challenges faced when implementing CBT for HD in patients with severe heart disease. This is an important limitation to reconcile given the preponderance to heart disease in patients with HD, and the potential that sorting and discarding of possession, a key component frontline treatments for HD [11, 12], could lead to an increased cardiovascular response [6]. Therefore, the aim of the present study was to report on three patients with HD who were hospitalized for decompensated heart failure (HF). A detailed case-study is then presented to illustrate the therapeutic techniques, challenges faced, and suggested modifications when implementing CBT for HD in the patient population with comorbid HF.