Internalized Anger as a Trigger for Picking and Pulling

Soon after my clients begin treatment for picking and/or pulling, I tend to bring up the topic of anger. This is not a topic most of my clients are comfortable discussing. 

Over the years, I’ve noticed that many pickers and pullers bottle up their anger rather than expressing it, and that this internalized anger often becomes a trigger for their body-focused repetitive behaviors (BFRBs). Suppressing anger can be a useful coping mechanism, as parents and others may react negatively to its expression, and reversing this ingrained response often feels like a dangerous and overwhelming proposition.

In 2016, Curley, Tung & Keuthen published a study titled “Trait Anger, Anger Expression, and Anger Control in Trichotillomania: Evidence for the Emotion Regulation Model.” The study focuses on the connection between the internalization of anger and BFRBs. 

Their conclusions validate my focus on helping my clients to express their anger. "This study demonstrates that there is a clear relationship between TTM [trichotillomania] and anger directed inward. Individuals with TTM have both a tendency to suppress anger and difficulty controlling and reducing this inward expression of anger, suggesting that hair pullers may have trouble regulating their anger" (p. 79).

One way I can help my clients reduce the stress in their "stress cups," (see May's blog below) and take pressure off the need to pick or pull is to help them regulate their anger effectively instead of turning it inward. This process involves several steps:

1.    Identify angry feelings and locate them in the body.
Many who struggle with BFRBs have turned off internal emotional sensors, especially those related to anger, in order to cope with their environments. When I am with a client, I often notice cues that they are angry or irritated, either with me or with someone else. These cues might include using a curse word or slapping a knee while talking. In these moments, I can help them check in with their bodies to see if there might be some tightness or other sensation somewhere inside. I can help to name this sensation as anger and take some of its power away. As we go along, we can begin connect what we were talking about in our session with that uneasy feeling.

2.    Understand how suppressing feelings has worked as a coping mechanism.

Anger can feel very scary. Many people have valid fears about what might happen if they turn their aggressive impulses toward others. We can begin to understand the ways anger at others is turned toward the self through negative self-talk and engagment in BFRBs. Once the reliance on self-defeating behaviors is understood, it is easier to consider that an outward expression of anger might be safe in a new, healthier environment. 

3.    Develop emotional regulation skills. 

I encourage clients to express their anger or frustration at me when it arises. By encouraging the expression of anger in the moment, I can help them them to begin to calm themselves down. Neurobiological research explains how a therapist's calm and centered presence can help clients begin to relax their central nervous systems.  My response to a client's dissatisfaction with me is to validate and invite negative feedback. I explain that their expression of anger helps me to get to know them and can help me understand how to be a better therapist. In order to help them to bring these regulation strategies into their daily lives, I often share the metaphor of an anger pendulum. I explain that if we’ve been repressing anger, we may be clumsy when we try to express it, sometimes blowing up or saying hurtful things, moving from passive to aggressive. Luckily, as we get more comfortable with our angry feelings, we can begin to communicate them more effectively and move into the middle ground between passivity and aggression,  assertiveness. Additionally, I often encourage physical activity as an emotional release.

It takes courage to get in touch with feelings that have we have repressed like grief and anger. The good news is that our bodies have all of the information we need to cue in to these unwanted feelings and begin to befriend them. A therapist's presence can make it easier to relax while discussing painful feelings and begin to soften the pain we have been trying to avoid. Once we are comfortable with expressing our anger in healthy, productive ways, we may notice less pressure on the stress cup that contributes to engagement in picking and pulling. 


Curley, E., Tung, E. & Keuthen, N. (2016). Trait anger, anger expression, and anger control in trichotillomania: Evidence for the emotion regulation model. Journal of Obsessive-Compulsive and Related Disorders, 9, 77-81.