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.