Are OCD, Hoarding and Trichotillomania Related Disorders?




Whether hoarding is an illness or a symptom of something else is subject to debate. Does it make sense that people who voluntarily rid themselves of their hair through pulling, technically known as trichotillomania, would also be hoarders?

The psychological disorder broadly referred to as hoarding currently receives a lot of attention through several television programs — A&E’s Hoarders, TLC’s Hoarding: Buried Alive and Animal Planet’s Confessions: Animal Hoarding — and increased news coverage of hoarding incidents.
In an extreme case in 2010, a 79-year-old woman in Skokie, Ill., died from a heart attack in her debris-packed home when emergency medical technicians were unable to work their way through piles of furniture, boxes and garbage stacked 6 feet high. Her body was removed from the home by cutting a hole through the roof.

So what exactly is hoarding all about? To understand hoarding and determine if you or someone you know might be a hoarder, it helps to get past the gawking nature of reality television. We spoke with psychiatrists and psychologists and stumbled across the sense there sometimes is a connection between trichotillomania — hair pulling, a certifiable obsessive-compulsive disorder (OCD)  — and hoarding.

It was a hair replacement stylist, Helen Owens, who provided direct insight into the relationship that may exist between hair and hoarding. The proprietor of Klassic’s International in Tracy, Calif., Owens typically works with female clients who have alopecia areata. However she has seen several clients whose hair loss was due to hair pulling instead.

“These women would not reveal their hair loss was from their own hand until I prodded them,” says Owens. “I also found that one of the characteristics of this disorder was disorganization and erratic behavior. As a hair replacement professional, I had already developed a great deal of patience, but I found that with my ‘trich’ clients I had to not only be patient but definitive, as some of their mental thoughts and listening skills can sometimes be a bit scattered. In fact, I have one client who I have serviced in her home for years. When I go to see her, [I] allow myself several minutes before and after the appointment to clean up so I can have a clear area to work in.”

Owens acknowledges that this individual’s disorganized, erratic behaviors may not achieve a full-blown hoarding diagnosis. But it appears to her that “hoarding is in fact an OCD behavior.”

The APA position on hoarding

Whether hoarding is an illness or a symptom of something else is subject to debate. The American Psychiatric Association (APA) is mulling where hoarding might fall in the spectrum of obsessive-compulsive disorders and how to classify it in the next official manual of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V).
The proposed revision to the current DSM defines hoarding disorder as having several components:

  1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
  2. This difficulty is due to strong urges to save items and/or distress associated with discarding.
  3. The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible. If all living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
  4. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
  5. The hoarding symptoms are not due to a general medical condition (e.g., brain injury, cerebrovascular disease).
  6. The hoarding symptoms are not restricted to the symptoms of another mental disorder (e.g., hoarding due to obsessions in Obsessive-Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia or another Psychotic Disorder, cognitive deficits in Dementia, restricted interests in Autism Spectrum Disorder, food storing in Prader-Willi Syndrome).

The APA definition also looks at whether the collecting, buying or stealing of items occurs when there is no need for such items or no available space. Additionally, the organization suggests weighing the degree to which the hoarder is aware of the problems created by the hoarding behavior (some are, and some are not).

Therapists and professional organizers observe hoarding and trich

Several therapists and professional organizers shared with us their observations on hoarding from direct personal observations and experiences:
RK:Where is the line drawn between being disorganized or messy and true hoarding?

Alice Price, certified professional organizer in chronic disorganization (CPO-CD) and owner of Organize Long Island Inc.: “Simply put, the line is in the functionality. When multiple rooms totally lose their functionality, we are looking at hoarding. When food cannot be prepared in a kitchen, when a bed cannot be slept in, when the stuff makes bathing impossible — there is a true hoarding situation. My experience is that some hoarders have OCD and suffer great anxiety about discarding things. Others, however, have no problem with the volume of accumulation. In that case, the hoarder doesn’t want to discard anything because they see the value and/or the use possibility of every item. In the latter situation, there is no anxiety involved and thus, I believe, should not be considered OCD.”

Christine Shuck, owner of Creative Solutions, a professional organizing firm: “I believe hoarding to be an extreme form of collecting that has gone out of control. There is this compulsion, this need to gather things, much as a magpie would feather its nest. It could be anything, and it isn’t necessarily related to one object alone. For example, there are the cat collectors, who take in so many cats they cannot possibly care for them. Or houses filled with what is essentially trash, because they see an innate worth in the trash and hate the waste. The line between disorganization and true, life-altering hoarding is rather clear — when your quality of life is affected by hoarding, when it becomes dangerous in your own home due to an excess of animals (along with feces, dander and disease) or a fire and health hazard (stacks of stuff, pathways through the clutter, etcetera) — then you have hoarding.”

RK:There is some disagreement as to whether hoarding is an OCD behavior or something else. What is the contrary thinking?

Elizabeth R. Lombardo, Ph.D., M.S., P.T. and author of A Happy You: Your Ultimate Prescription for Happiness(Morgan James, 2009): “While some hoarding is related to OCD, not all is. OCD is characterized by the intense thoughts (obsessions) that cause significant anxiety. In an attempt to lessen their stress, people with OCD perform certain behaviors (compulsions) that temporarily reduce the anxiety. In the long term, however, these behaviors actually make their OCD worse. As a psychologist, physical therapist and author, I help people overcome issues like OCD.”

Lombardo says she has worked with various individuals suffering from trichotillomania and has been successful at teaching them how to stop the behavior.

RK:What tactics do you use to get people to just simply rid themselves of things?
Susan Fleischman, president of ClutterFree, a professional organizing firm in Chicago: “I ask them to answer key questions: When was the last time you used it? When do you think you’ll use it again? Do you love it? Why do you want to keep it? Then I suggest that we keep it in ‘another format’ that requires far less storage space, for example, take photos of key items and put them in an existing photo album or scrapbook. Parents save tons of kids’ artwork. Instead, take photos and make a ‘coffee table’ art book — now easy and inexpensive through various online programs or at Walgreens! If necessary, set aside in a ‘TBD Box’ for one month. Come back to it in a month and see if they change their mind. Especially if they see or realize there is no place left to store it. If they still want to keep things, I suggest offsite storage, and they typically don’t want to spend the money. So out the item goes! And last resort, I use tough love. Often, folks just need a gentle but firm kick in the butt!”
RK:What can be done to stop hoarding?

Marla W. Deibler, Psy.D., director of The Center for Emotional Health in Cherry Hill, New Jersey, has appeared on the A&E show Hoarders as well as several additional national media outlets. She works with both patients who are hoarders and those who have OCD: “Although some individuals with compulsive hoarding respond to antidepressant medication, many individuals do not. Cognitive-behavioral therapy, which involves helping individuals to change they way they think about and make decisions about their possessions in order to control the behavior, has been demonstrated to be helpful in the treatment of compulsive hoarding. This process involves behavioral assessment, psychoeducation, exposure/response prevention, cognitive restructuring and excavation exposure.” Regarding trichotillomania, Dr. Deibler also notes, “The most consistently empirically supported treatment for trichotillomania is cognitive-behavioral therapy (CBT) … [which] involves identifying ‘triggers’ to pulling behavior as well as ways in which to interrupt the pattern of behavior and redirect the response to pulling ‘triggers.’  Some individuals have benefitted from medication as well. Many individuals find participating in a support group and having contact with others who have trichotillomania and other BFRBs [body-focused repetitive behaviors] very helpful.”

RK:Is there another explanation for filling one’s home with things, perhaps that some people just hate waste?

Rick Aster, economist and author: “I am an economist and the author of the book Fear of Nothing: “No Clutter, No To-Do List, A New Day” [Breakfast Communications, 2009], which addresses the issue of clutter. I provide an economic perspective on hoarding. In economic theory, hoarding is something everyone does under certain circumstances. People hoard when they expect products to become unavailable or prices to rise. Or, it could be that people are afraid their incomes may fall. Virtually everyone keeps more possessions than they ideally should, in part because of exaggerated ideas of the value of things (‘someone will want this’ or ‘I could use this someday’). I believe it is helpful to separate excess possessions that come from simple miscalculations from those of compulsive hoarding. Most people just need to change the way they calculate the costs and value of things. But then, there are people who need more help than this.

“People use fewer of their possessions than they realize. The average person uses about 10 percent of their possessions over the course of a year. I consider that normal, though the ideal would be closer to 50 percent. If someone is using about 1 percent of their possessions, then there is a strong chance that it is a pattern of compulsive hoarding. The real test, though, is whether people can throw things away. If, realizing that you have too much stuff, you can go through it and throw 1 percent of it away without great difficulty, then you are not a compulsive hoarder, just someone whose life is out of balance.”

Owens, the hair replacement stylist who works with trichotillomania patients, says she believes she enables about a quarter of her trich clients to overcome their compulsive hair pulling with the use of a hair weave prosthesis in combination with simply talking it through with them. But she refers many clients — both hoarders and hair pullers — to professional therapists, including those they can find through the Trichotillomania Learning Center for professional counseling.
Clutter, disorganization, clinically diagnosed hoarding — all are similar behaviors with perhaps widely varying causes and at least a shred of connection to compulsive hair pulling. It helps to know when you or a loved one is engaged in any of these, when it becomes a problem and when it is time to seek professional help.