A 21-year-old college student presents requesting a referral for rhinoplasty. She spends 3-4 hours daily examining her nose in mirrors and takes elaborate photographs from different angles. She frequently asks her roommate if her nose looks 'deformed,' though her roommate and family see nothing abnormal. She has missed multiple classes because she feels too self-conscious to be seen in public, has switched to online courses, and has consulted three plastic surgeons — all of whom declined to operate, stating her nose appears normal. The PMHNP suspects body dysmorphic disorder. Which feature most strongly supports that diagnosis?