A 17-year-old girl is referred to the PMHNP after pulling her eyebrow hair out to the point of scarring. She says she has a "unibrow" and looks like a "Neanderthal" unless she pulls out the hair. The PMHNP asks to see a photo of the patient before she started pulling out her hair, and it was not unusual. What is the most appropriate diagnosis?

Choice A reason: Body dysmorphic disorder involves preoccupation with a perceived defect in appearance that is not observable or appears slight to others. In this case, her concern is secondary to hair-pulling behavior rather than a primary body image distortion. Choice B reason: Delusional disorder, somatic type, involves fixed false beliefs about bodily functions or appearance. The patient does not have delusional beliefs but engages in repetitive hair-pulling behavior. Choice C reason: This is correct. Trichotillomania is a body-focused repetitive behavior characterized by recurrent hair-pulling, resulting in noticeable hair loss or scarring, accompanied by distress or functional impairment. The patient’s pattern of pulling and distress fits the diagnostic criteria. Choice D reason: Normal age-appropriate concerns about appearance would not involve repetitive behaviors causing scarring. The severity and physical consequences distinguish this from typical adolescent self-consciousness.