A 25-year-old married woman explains to the PMHNP that she spends an inordinate amount of time tweezing her eyebrows every evening. She says she has anxiety when she looks in the mirror and sees asymmetry in her eyebrows. She tries to pull every hair that is out of place. This can take more than an hour each evening, and it is becoming problematic because she is still unhappy after tweezing. She only stops when her husband demands it, after telling her how beautiful she is and that the asymmetry is "all in her head." She still feels an urge to tweeze her eyebrows every night in an attempt to "fix" them. What diagnosis is the most appropriate?

Choice A reason: Trichotillomania involves hair pulling often due to tension or boredom without a preoccupation with symmetry. In this case, the pulling is driven by a compulsion for symmetry, making this diagnosis less appropriate. Choice B reason: BDD involves distress over perceived physical flaws. While the patient is concerned about asymmetry, the hair pulling is specifically performed to alleviate compulsive distress, consistent with OCD rather than BDD. Choice C reason: Delusional disorder, somatic type, involves a fixed false belief about bodily functions or appearance. The patient acknowledges the asymmetry is "all in her head," indicating insight, which rules out delusional disorder. Choice D reason: OCD is characterized by obsessions (distressing thoughts) and compulsions (ritualized behaviors to alleviate distress). The patient’s repetitive eyebrow tweezing to achieve symmetry despite knowing it is unnecessary reflects a compulsion, confirming OCD.