A 14-year-old girl is brought to the office by her mother due to unusual behavior over the past year. The mother is concerned that her daughter seems overly anxious about eating, and says, "During lunch, she spent 45 minutes cutting the broccoli on her plate until all the pieces were the same size." The patient recently became a vegetarian and spends hours in the grocery store selecting vegetables and checking nutritional information. She also seems very concerned about her appearance; she brushes her hair 21 times on each side, parts her hair strand by strand, and plucks her eyebrows for an hour daily. The patient says, "If I don't keep things exactly even I'm afraid something bad might happen." The patient is medically healthy and has not yet started menstruating. She weighs 45.8 kg (101 lb) and is 157.5 cm (5 ft 2 in) tall. BMI is 18.5 kg/m². Physical examination is normal with the exception of extremely sparse eyebrows. Which of the following is the most likely primary diagnosis?

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11ec160b_3631_61d0_9249_61b60eab1ded_MD0001_00 This patient's repetitive behaviors with food and grooming appear to be compulsions performed in response to an obsession with symmetry and exactness, which is consistent with a primary diagnosis of obsessive-compulsive disorder (OCD). Obsessions are persistent and unwanted thoughts, urges, or images that often drive an individual to perform compulsions: ritualistic behaviors or mental acts (eg, counting) to alleviate anxiety or prevent a feared event. In this situation, the patient's obsession with symmetry results in compulsions to cut her food into uniform pieces and groom her hair evenly to prevent a bad outcome. Compulsive behaviors in OCD are often illogical (eg, skipping over sidewalk cracks to prevent injury to a relative) or are excessive in nature (eg, checking if the front door is locked 50 times a day). For diagnosis, obsessions or compulsions must be time-consuming (>1 hr/day) or cause significant distress or functional impairment. OCD is typically a chronic disorder starting in childhood or adolescence. (Choice A) This patient has a normal BMI based on age and sex, and her unusual eating behaviors are related to her obsessions and compulsions rather than intense fear of weight gain. (Choice B) In body dysmorphic disorder, individuals have a preoccupation with perceived defects in physical appearance. In contrast, this patient's eating and grooming rituals are driven by a symmetry obsession and the need to prevent a feared event. (Choice C) Generalized anxiety disorder involves excessive worry about multiple issues and is not associated with intrusive thoughts and compulsive behaviors. (Choice E) Obsessive-compulsive personality disorder involves a lifelong pattern of insistence on control, orderliness, and perfection and does not include frank obsessions and compulsions that are present in OCD. Personality disorders are generally not diagnosed before age 18 (or in young adolescents) and would not explain this patient's recurrent compulsions performed in response to anxiety-inducing obsessions. (Choice F) Trichotillomania (hair-pulling disorder) involves recurrent pulling of hair and repeated attempts to decrease or stop the behavior. It would not be diagnosed in this patient who pulls out her hair as part of a symmetry obsession and compulsions. Educational objective: Obsessive-compulsive disorder is characterized by persistent, unwanted thoughts (obsessions) and repetitive, time-consuming rituals (compulsions) that the individual feels driven to perform to alleviate anxiety. __________ References: Obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24576790) Obsessive-compulsive disorder: advances in diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28384832) Obsessive-compulsive disorder in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/25398447)

A 14-Year-Old Girl Is Brought to the Office by Her