Trichotillomania (Hair-Pulling Disorder) 251
ing onerous rituals (e.g., not discarding object s in order to avoid endless washing or check-
ing rituals).
In OCD, the behavior is gene rally unwanted and highly distressing, and the individual ex-
periences no pleasure or reward from it. Excessive acquisition is  usually not present; if exces-
sive acquisition is present, items are acquired because of a specific obsession (e.g., the need to
buy items that have been accidentally touched in order to avoid cont aminating other people),
not because of a genuine desire to possess the items. Individuals who hoard in the context of
OCD are also more likely to accumulate bizarre it ems, such as trash, feces, urine, nails, hair,
used diapers, or rotten food. Accumulation of su ch items is very unusual in hoarding disorder.
When severe hoarding appears concurrently  with other typical symptoms of OCD but
is judged to be independent from these symptoms, both hoarding disorder and OCD may
be diagnosed. 
Neurocognitive disorders. Hoarding disorder is not diagnosed if the accumulation of
objects is judged to be a direct consequence of a degenerati ve disorder, such as neurocog-
nitive disorder associated wi th frontotemporal lobar degeneration or Alzheimer’s disease.
Typically, onset of the accumu lating behavior is gradual and follows onset of the neuro-
cognitive disorder. The accumulating behavior  may be accompanied by self-neglect and
severe domestic squalor, alongside other neuropsychiatric symptoms, such as disinhibi-
tion, gambling, rituals/stereotypies, tics, and self-injurious behaviors. 
Comorbidity
Approximately 75% of individuals with hoardi ng disorder have a comorbid mood or anx-