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.