A 19-year-old female college student presents with noticeable hair loss on her scalp. She describes an increasing sense of tension before pulling out her hair and a feeling of relief or gratification afterward. She has been pulling her hair since age 13 and has tried to stop multiple times without success. Examination reveals patchy alopecia on the crown of her scalp with hairs of varying lengths. She denies skin lesions, rashes, or other dermatological symptoms. She does not endorse intrusive thoughts about contamination or symmetry driving the behavior.