Groundbreaking Insights Into Narcissism and Treatment

You. I'd like to welcome everybody to. To today's counselor education presentation on new insights regarding narcissistic personality and narcissistic behaviors. I'm your host, Dr. Donnelly Snipes. Today we're going to explore the unique physiological and neurological traits of individuals with npd. Yeah, they're actually wired differently. We'll explore how inflammation and gut dysbiosis may contribute to symptoms, review factors that may have contributed to the development of their symptoms, identify strategies to build rapport and engage, and then identify treatment strategies. First thing, I want to start off with, and I've said this a bunch of times before, behavior is caused by something. We are triggered, motivated, stimulated to act, to behave based on something. Behavior that's reinforced will increase. So if when I throw a temper tantrum, I get my way, then you can darn well bet I'm going to throw that temper tantrum again to get my way. If the behavior is punished, it will decrease. So in some people with narcissistic traits, we may see behaviors that have evolved because they've been rewarded, they've been reinforced. And remember, with a personality disorder, the behavior has to have been present since late adolescence, early adulthood. The behavior has to be inflexible and it has to be pervasive in most areas of the person's life. Not just at work, not just with intimate relationships. It has to infiltrate or permeate every aspect of the person's life. Otherwise, it's just narcissistic traits. Now, if you're working with somebody who has narcissistic traits, your boss, for example, it can be an unpleasant experience. No doubt so. But recognizing the difference between the personality disorder diagnosis and trust traits that may have developed and been reinforced in particular situations for that particular person. Now that those behaviors may still not be working with them, working for them effectively, but it is important to differentiate. So let's talk about the neurological and physiological mechanisms. A lot of times we just talk about personality disorders like they pop up out of nowhere. They don't. People do not develop these behaviors unless they're rewarded or reinforced in some way for. So we need to ask, what caused that initial behavior? What caused this person to do this the first time so it could get rewarded? Emerging research highlights significant neurobiological and physiological contributors to narcissistic personality behaviors, including differences in brain structure and function, autonomic nervous system disregulation. Gee, where have we heard that before? Inflammatory processes. Hm. Oxidative stress, and gut microbiome composition. If you've been with me for the past three, four, five weeks, you've heard these things over and over and over again. And I think it's vital that we start recognizing the impact that our body has on how we interact with the world. Studies have identified structural differences in the prefrontal cortex, insula and limbic system in individuals with narcissistic personality disorder. If we want to think of narcissistic personality kind of being on a spectrum, you have narcissistic personality over here, disorder over here, or where it is pervasive, it is rigid, inflexible, yada yada. And then you have people who have narcissistic traits that may be in one or more areas of their life. And it's kind of on a continuum. But we want to ask ourselves where on the continuum is this person in terms of how their brain might be constructed differently? The medial prefrontal cortex, we see increased volume and activity associated with self referential processing and grandiosity. This is sort of the, I think medial prefrontal as the me part of the brain. It's all about me self referential processing and grandiosity, which reinforces rigid self enhancement and difficulties integrating negative feedback. It's the very egocentric part of your prefrontal cortex, but it's more active and it's bigger in people with narcissistic personality disorder. Interesting. And remember that our brain develops neurons, we have, have neurogenesis developing neurons and strengthening areas that get used the most. And the areas that we don't use as much may become less, less big, may become smaller. There's also structural differences in the orbitofrontal cortex. Dysregulation contributes to impulsivity and poor reward processing, explaining entitlement driven behaviors and difficulty delaying gratification. Again, we're talking about that frontal cortex area where we have a lot of our executive functioning. And when this area is not working like it should, or when it's less active, then the person has difficulty with frustration tolerance and delay of gratification. And then the insular, insular cortex is associated with reduced activation and, and deficits in affective empathy, interoceptive awareness and reinforcing emotional attachment. We're going to talk about affective versus cognitive empathy a little later. But basically affective empathy is the ability to actually feel and understand what another person's feeling. Cognitive empathy is the ability to know what they're thinking or feeling, saying okay, I can see that you're upset, I can see that you're angry, or this is probably going to make you angry, but affective empathy is when you actually feel it. We want to ask ourselves, is in the person with narcissistic behaviors, why are these brain regions different? What happened? Is it genetic? There's only a small part of NPD that's genetic. A lot of it you're going to find out comes from ans dysregulation and trauma. Which takes us to ans dysregulation, your autonomic nervous system, your fight or flight and rest and digest, or your sympathetic and your parasympathetic or your stress response and your relaxation response, whatever you want to call it. I wish we could just call it one thing, but your ans, your autonomic nervous system is sort of your automatic nervous system. And chronic HPA axis activation, chronic activation of that stress response, that sympathetic nervous system, leads to reduced strength and tone in the relaxation response or the parasympathetic nervous system. This contributes to hypersensitivity, to criticism, emotional volatility and impulsive reactions. When people have dysregulation of their stress response, they will go from fine or flat to furious or frantic like that. And there's a neurological component to it. It's not just they're choosing to do that. It is that their body floods their brain with a whole lot more of those stress chemicals than what we see in a person who doesn't have this problem. So the chronic HPA axis activation really starts leading to that imbalance and we call it sympathetic dominance, where that stress response is just all over, you know, super strong, poor vagal tone may impair emotional regulation and social engagement, reinforcing interpersonal exploitation and dominance seeking behaviors. So let's back this up and kind of think about it in real world, real world terms. If I am stressed out all the time, if I am feeling unsafe, if I am hypervigilant to what's going on around me, why, we're not sure yet. But something has caused me to be hyp hyper hyper vigilant and hypersensitive to criticism. It's caused my stress response to become disregulated. So I have a much stronger reaction to stressors in my environment because that sympathetic nervous system is so much stronger. The vagus nerve can't turn it down. The vagus nerve is part of the parasympathetic nervous system and it's supposed to turn it down. But when we have poor vagal tone, it means the rest and digest can't turn down the stress response. So the stress response is just running wild. Well, when we're stressed, do we Regulate our emotions? Well, no. When we're stressed, are we effective at perspective taking and empathy and social engagement and compassion? Generally not. Which is why in these particular individuals, they may have engaged in behaviors such as interpersonal exploitation or dominance seeking. In order to feel safe, I am going to control this situation, so I feel safe. And that got rewarded. Therefore, those behaviors began to become part of that person's repertoire. Oxidative stress is something that happens as we have these chemical reactions in our body. Throughout the day, when we breathe, when we eat, when we move, when we do whatever. There are byproducts. And these byproducts usually get cleared out pretty easily. However, when we're producing more byproducts than our body can clear out, it produces oxidative stress. When we have this garbage, think of it that way. Garbage building up in our system, it leads to the development of inflammation. Oxidative stress is directly correlated to inflammation. And remember, inflammation a lot of times is not localized. It be especially in people with a dysregulated autonomic nervous system. Inflammation is systemic, including in the brain. Elevated levels of biomarkers for oxidative stress have been observed in individuals with narcissistic personality disorder. This suggests heightened physiological stress responses and neuroinflammation. They recognize that people with NPD tend to have stronger stress reactions per produce more garbage, if you will, from those activities and have a more difficult time clearing them from their body, which leads to that neuroinflammation. Another thing supporting this is that we also see increased pro inflammatory cytokines. So molecules in our body that indicate that there's in inflammation correlate with interpersonal hypersensitivity, mood instability and impulsivity. As we have more inflammation in our body, why do you think it would make us more hypersensitive interpersonally? Because we're exhausted, because we are in pain, because our when we have systemic inflammation, it. It increases the activation of that stress response. So inflammation itself can make us stressed and irritable and edgy, which can make us more interpersonally hypersensitive. Especially if we grew up in an environment where we needed to be interpersonally hypersensitive to stay safe, we needed to look for those micro expressions that told us what was going to come next. When we have inflammation, when we have neuroinflammation, when we have ans dysregulation, we're going to have mood instability and typically impulsivity. Because when you're in fight or flight, when that stress response is activated, the body's not in. Let's think about the best way to handle this. It's in the. Let's get away from the hungry lion. So you're more likely when you're stressed out to respond impulsively. And since the person with NPD tends to be sort of perpetually in a stressed state, then we may see more of these behaviors. All of this, the oxidative stress, inflammation, impulsivity, emotional disregulation, is linked to the disregulation of that stress response. Several core symptoms of narcissistic personality, as well as just narcissistic behaviors in including interpersonal hypersensitivity, grandiosity, entitlement and lack of empathy may be linked to the gut microbiome related stress response. I actually put two of the most fascinating articles I read at the bottom here and at the end of this presentation I have a references list if you want to go read some of these articles. But both of these identify the correlation of between the makeup of your gut microbiome and the expressed personality traits. It's absolutely fascinating. Anyway, reduced gut microbiome diversity has been associated with higher neuroticism, stress reactivity and social dysfunction. When we are stressed, it creates neuroinflammation, which changes the environment of our gut. So think about it like turning up the heat. The not everybody likes to be in a sweat box. So turning up the heat in our gut, which, not exactly what's happening, but follow my metaphor. The healthy microbes, the ones we need to feel happy and motivated and all those other things, they start going away, they, they die off, whatever. And then you're left with the pathogenic microbes that are fewer in, fewer in number and fewer in diversity. But they're there and they're strong. These behaviors that emerge when we see lower microbiome diversity suggests a gut brain access contribution to emotional instability and interpersonal regulation. Now, there are lots of studies out there where they have increased and a lot of these are done on mice, but they have increased a certain microbe excessively in, in the my mouse. And it really has altered that mouse's behavior significantly, which is, is amazing. I haven't seen as many with humans, but they have done a few studies with humans where they actually used particular antibiotics to wipe out certain strains of bacteria and it altered the interpersonal behaviors of, of the patient. Dysbiosis, or getting that microbiome all out of whack contributes to HPA axis over activation. Just like when there's inflammation, the body says, ooh, this is not Right. There's a threat, there's a stressor and it increases HPA axis over activation. When the gut microbiome is out of balance, the brain says ooh, there's a problem and it increases the HPA axis. This leads to increased cortisol, emotional reactivity and interpersonal hypersensitivity. Dysbiosis driven chronic inflammation and stress sensitivity contributes to impulsivity, poor frustration tolerance and exaggerated need for control. And again, HPA axis overactivation contributes to dysbiosis and dysbiosis contributes to HPA axis overactivation. Therefore, there is a very clear path here for a ancillary treatment or approach for people who have some of these traits. Neuroticism, difficulties with impulsivity, etc by virtue of helping them improve their diet with and adding some probiotics and prebiotic things in order to heal that gut and take some of the stress off, reduce some of that activation of the HPA axis that's coming directly from the gut. Dysbiosis, poor diet, stress, anxiety and my favorite, poor sleep were all associated with increased inflammation, HPA axis activation, gut dysbiosis, emotional instability and impulsivity and lower microbe diversity. And, and I keep saying what's causing these changes? What's causing the ANS activity? Dysregulation, what's causing the gut dysbiosis? What's causing the changes in the brain structure? We need to look back and say when did this start? Did this start in utero? For some people it does. Sometimes it's genetic, sometimes it's because their, their mom was under a lot of stress and they were being exposed to a lot of stress hormones from the get go. There are also other studies that have shown that birth method alters the diversity in the microbiome and whether a baby is breastfed or drinking formula alters the gut micro diversity. Those are all things we want to look at in terms of just understanding how this develops. But we can't go backwards and say, well you need to not be born by C section. That's not going to, that's not happening. So what can we do now to recognize that this person has low microbe diversity, has systemic inflammation and sympathetic dominance? We can help them increase their microbial diversity through a good diet and reduce stress. We can help them strengthen their vagal tone in order to balance that sympathetic and parasympathetic nervous system and we can help them overall try to reduce unnecessary stress. As those things are healed. Inflammation is going to go down unless there's some other illness. That's causing that inflammation. NPD is characterized by distorted self esteem regulation, impaired empathy and maladaptive relational strategies. Part of this could be caused by early socialization and peer influences. They've found that adolescents exposed to excessive social comparison and status competition may develop rigid self enhancement schemas. If the child is loved for what they do, not who they are, if they don't have that unconditional positive regard, if the child is regularly compared to other children or their siblings, or they have to fight to get noticed in their family, they may develop some of these rigid self enhancement schemas to help themselves feel safe and to survive that environment where they feel ignored or abandoned or insecure. NPD involves unstable self esteem regulation rather than uniformly high or low self esteem. A lot of people with NPD have areas where they have high self esteem or times when they have high self esteem and areas or times when they have really low self esteem. And for somebody with npd, many times the not always, but many times if they experience criticism, rejection or failure, they may have had a high self esteem in this area, maybe at work, and then they fail and it just pops that bubble and they don't know what to do now and and so that their self esteem takes a huge hit. If all of a sudden they have this epiphany that maybe they are not the most brilliant grandiose narcissists maintain self worth through external validation and dominance. Well, that makes sense. If I am thinking that I'm all that a bag of chips and more, then I am going to need somebody to make to tell me that, you know, I can't exist in a world where everybody's telling me no, you're not all that. So I am going to seek out people who will validate me and I am going to seek out situations where I can dominate and I am going to sort of gravitate towards those situations because that's where I feel safe. Vulnerable narcissists experience frequent self doubt and they're hypersensitive to criticism. Therefore they may be more actually more avoidant in some of the things that they do because they are afraid that somebody's going to find out that they're not good enough. Inconsistent or conditional parental validation creates fragile self esteem and reliance on external reinforcement. We've talked about this so many times in the videos on attachment, secure attachment, insecure attachment. Children need an environment where their caregivers help them feel safe and empowered and loved based on being consistent, attentive, responsive, encouraging and safe. Safe means I'm Going to encourage you to step out of your comfort zone. And if you succeed, great, I'm going to cheer you on. And if you fail, no big deal. Come on back. I love you anyway. So safe is that unconditional positive. Regardless, people with narcissistic personality almost never experienced this. Even if they were overindulged as children, which the parent may have thought was how they expressed love. If the child didn't feel safe in that environment, then they may have, you know, developed attachment trauma. Early emotional neglect is associated with entitlement, interpersonal exploitation and poor distress tolerance. When people are experience adverse childhood experiences early on, cognitively, they're still thinking egocentrically, they're still thinking in all or nothing terms, they're still thinking in a very personalized it's all about me sort of way. And so that early emotional neglect created a situation, created an attachment disruption that the person kind of got stuck. And if you think about these behaviors, a lot of times what we see in people acting out entitlement and interpersonal exploitation and poor distress tolerance in adulthood, it kind of looks like a three or a four year old throwing a temper tantrum. And essentially that may be one of those places where they kind of got stuck, if you will, because once they experienced that attachment trauma, they pretty much didn't get out of fight or flight. They pretty much didn't suddenly feel safe and empowered so they could examine things. And if they were being neglected, that means they probably didn't have a caregiver that was there to help them develop emotional intelligence. And that was helped them, that was there to help them develop the skills to evaluate the situation and determine what's fair, what's not fair, what's really going on here. They didn't have anybody to teach them those skills. And you know what, we're not born with them. We have to learn these skills. And that comes through secure attachment. Overindulgence in childhood, permissive parenting and over praise without realistic feedback contribute to exaggerated self importance and, and unrealistic expectations of special treatment. Remember at the beginning I said what, what's reinforced tends to become stronger. And in these particular situations, the child never really experiences loss or failure or hardship. They're always winners and they are praised for everything. And the feedback is that you can do whatever you want, you can do everything all the time. And that's not realistic. You can do a lot of things, but everything all the time. Not really, not really realistic. On the other side of the coin, authoritarian parenting may contribute to compensatory grandiosity perfectionism and emotional suppression. If the parent is really critical, then the child may feel like they've got to prove that they're worthy of love through being perfect and unemotional. Because when they are imperfect or emotional that gets criticized in terms of a paired empathy and emotional reciprocity. People with NPD and narcissistic traits often retain cognitive empathy. Empathy, they understand others emotions. I understand you're sad, I understand you're angry. But they lack the ability to actually feel those emotions. And in reciprocity which allows them to manipulate without guilt, it's I see you're sad or I see you're terrified. Sucks to be you. In in instead of what most of us experience where our heart breaks or you know, we want to rescue them or whatever it is when we see somebody suffering. The person with NPD may understand the emotion but not actually feel it. Individuals with and I will say, I will say Remember in the DSM 5TR to get a diagnosis of just about anything, you only need some of the characteristics. Empathy is one of the characteristics of narcissistic personality. Therefore you can safely say that some people with narcissistic personality do have empathy, but they have a lot of other symptoms that go along with it. So lack of empathy is not required for an NPD diagnosis. Individuals with NPD may disengage empathy when it threatens their superiority or engage it when it serves their goals. Some people have empathy and they can turn it on and off. I'm going to care, I'm not going to care. I'm going to understand but not feel or I'm going to understand and feel. They actually have fine tuned it so it doesn't hurt so much if they do choose to empathize. In terms of emotional processing deficits in NPD we may see intense reactivity, suppression of feelings and maladaptive coping mechanisms. People with NPD tend to have high autonomic arousal. Their sympathetic stress response is really strong and when it gets activated it's 0 to 250. There is no middle ground. High autonomic arousal which leads them to be hypersensitive to criticism, rejection and status threats. They feel unsafe so they're constantly scanning for those threats. And when they see those threats they go into overdrive. They also have low distress tolerance. Well, when you're already stressed out to the max, you probably don't have a lot of distress tolerance. Let's just say what it is. I know when I'm really stressed out, my distress tolerance is not as good as it could be. Low distress tolerance contributes to impulsivity, rage reactions and interpersonal aggression. It's the forget about it, get away, I can't do it, whatever or I won't do it. For a lot of people with npd, the words can't. The, the word can't is not something that's in their vocabulary. I won't do it or this is your fault and you need to fix it. So there's a lot of blaming that may happen because they can't admit weakness, inadequacy, failure, etc. We also can see shame and avoidance of vulnerability in people with npd. Not all people with NPD have high self esteem or low self esteem. They have, you know, varying self esteems and NPD behaviors may function as a defense against deep seated shame. I don't feel that I'm enough. I don't feel that I'm lovable. Therefore I'm going to put on this great big facade, this grandiose facade and I'm going to control everybody around me just like the the wizard in the wizard of Oz. So nobody can see behind the curtain. This functions to protect them against deep seated shame leading to emotional detachment, perfectionism and grandiosity. Cognitive distortions in narcissism contribute to rigid self concepts, impulsivity and reward sensitivity. Cognitive distortions, all or nothing exaggeration, magnification, personalization. Whenever we use cognitive distortions, they're not helpful. They don't reduce our stress. In most cases they worsen our stress, they intensify our stress. So people with a lot of cognitive distortions tend to be more stressed out and may become more rigid in their self concept because they have difficulty testing it against other other things. People with NPD also exhibit reward processing and delay discounting differences than people without npd. They have heightened sensitivity to immediate rewards and diminished long term planning ability. We also see this not saying that people with ADHD are narcissistic by any means, but this is one of those behaviors we do see in people with ADHD where the immediate rewards how does this apply to me right now? Can often be more motivating than the long term rewards. Grandiosity correlates with impulsive decision making, reinforcing short term dominance behaviors. I'm all that and more and I am wanting this right now, whatever this reward is, so I'm gonna get it. And, and so we can see how that develops a lot of people who are impulsive. Why did you do that? Because I deserved it. So you see the impulsivity and the grandiosity can start going hand in hand. And there's cognitive rigidity. The person with narcissistic traits often thinks in those dichotomous ways. Remember I said back when they were a child, cognitively they may have gotten kind of stuck in that stage of cognitive development. And they never learn to challenge those dichotomies. They never learn to look at the what else is out there. Look at the grays, if you will. So the deck. Their dichotomous thinking reinforces inflexibility in self perception and interpersonal relationships and their reduced reality testing. And what we mean by that is their ability to look at the situation. Fit cat is not something that works for them. They have difficulty examining the facts in this context at this time in terms of, you know, objectively. They see it from their perspective and they see it from the way that enhances them and helps them stay more grandiose. Culturally, societies emphasizing individualism, material success and social media validation may exacerbate narcissistic tendencies by reinforcing self enhancement behaviors. Whether it is the filters you use on your Insta profile or making your life look like it's all that and more, or even the way people behave on social media and get rewarded for it if they behave in grandiose, invalidating, manipulative sort of ways. We see that a lot on social media and we see it get reinforced. So things that are reinforced are going to occur more often. What do we do about it? All that was to say there is more than just saying, well, this person was born this way and there's nothing that can be done. I want you to understand all of the things that led up to those brain changes and recognize that the brain can change again. We do have a fair amount of neuroplasticity. If we heal the body, we reduce that inflammation, we stabilize that autonomic nervous system, then we can help them move into a less narcissistic approach to life. Individuals with NPD often struggle with tolerating challenges, feedback and perceived authority figures. So when they walk into your office, they're already kind of defensive. We need to position ourselves as a collaborative consultant. And as we go through this, I'm going to give you a lot of sort of scenarios in the last half of this presentation. Because working with somebody with NPD is so much different in a lot of ways than working with every other person that walks into your office. Because of their resistance to challenges and feedback and, you know, taking advice from anyone else. They need to be in control. And I would encourage you to think of it from the perspective of why do they need to be in control? What happened to them that taught them that if they're not in control, if they're not perfect, if they're not grandiose, that the world is going to crumble around them. So try to approach it from that perspective and recognize that if we pop that bubble, they are going to be free falling and they don't like to be challenged. And a lot of times they'll disengage from treatment. So we need to develop rapport, position ourselves as a coach, as a consultant, not an authority figure. Explore what they want to get out of therapy and how they think you can help them. What is it that you would like me to assist you with? So leaving them in control, they're still in the driver's seat. Encourage them to work with you to define their rich and meaningful life so you can understand what's important to them. And eventually you're going to explore what's getting in the way of them achieving their goals. And a lot of times their obstacles are going to be framed from a standpoint of blame. This person doesn't understand me, this person is too emotional, blah, blah, blah, it's not about me. And we'll get there. But immediately challenging those perceptions is going to make the person with NPD feel very threatened. Avoid direct confrontation of grandiosity and reframe therapy as a way to refine their strengths and enhance personal mastery. As I said, approaching working with somebody with NPD is a whole different flavor than working with other people with other diagnoses. We need to respect their self perception without reinforcing the grandiosity. We're not going to confront it, but we're going to try not to reinforce it either. I like to think of it as taking the I standpoint. If the client comes in and says, I'm really smart. I have a bachelor's in psychology. I don't think there's anything you can do for me that I can't do for myself. Well, my first thought is, so why are you here? But that is not the appropriate response. The appropriate response is, that's great that you have such a strong interest and background in psychology. It will certainly make it easier for me to help you achieve your goals. So, all right, you're really smart. I have no facts that tell me you're not. You're really smart. That's going to make it easy for us to work together. Create curiosity rather than confrontation. The client says, I'm not a narcissist and I Don't need to be here. All right. Many people are called narcissistic these days when they're simply high achievers. I'm wondering who thinks you're narcissistic and what makes them think that. So we can start getting an understanding of other people's perceptions without obviously talking to those other people again. Frame therapy is an optimization tool to help them more effectively achieve their goals and live move toward their rich and meaningful life. It's not a corrective process, it's a coaching process. Focus on fine tuning their strengths to achieve even greater success. We're not going to fix what's wrong. It's like when we go into coaching is exactly that when we're coaching somebody, we're not eliminating a problem, we're helping them move toward a goal. And that's really what you need to focus on. So saying something like, you already have strong leadership skills or you've already accomplished so much, but it sounds like some interactions don't go as smoothly as you'd like. Let's see how we can refine that further. That is an approach we may take. We're being curious. We are saying, wow, it sounds like you already have these great skills, but it's not quite getting you there. So how can, how can we work together? How can we refine the strategy to help you get closer to that goal? Stay neutral and avoid power struggles. If the client devalues you, avoid defensiveness and reframe their criticisms as an opportunity for deeper self understanding. The client may say, I've read more about psychology than most therapists. The unhelpful response would be, that's unlikely. I've trained in this field for years or since you were in diapers. That's not going to be helpful. Helpful response. And anytime you feel yourself getting that head bob going, you know that's a defensive response. Don't go there. Helpful response, wow, that's great. What theories or approaches have you found to be most useful? This gets them talking and you can start understanding their perspective. If they've read a lot about in psychology, they've been trying to understand, they've been trying to figure out why they can't get to the next level. So let's capitalize on that. Use collaborative strengths based approaches to reflect their strengths while sudden, subtly questioning their rigidity. You can say things like, you know, you seem to have a really strong ability to command respect in professional settings. Do you find that works quite as well in your personal relationships or you're clearly skilled at influencing situations to Your advantage. Have there been times when that has backfired? And this can. If they have tried to influence somebody or to command respect in a situation and it's not working, then we want to look at they develop these behaviors. They were reinforced somewhere. So let's look at where they were reinforced. Oh, these behaviors, commanding respect was reinforced at work or I've had this happen a lot with people who did their entire career in their mil in the military and they try to use that same approach at home, barking orders and it doesn't, it doesn't translate. Helping them recognize or start to think about maybe I need to change my approach now, they need to come to that. But just kind of throwing that out there. Do you find that the stuff that works for you at work works as effectively in this situation or with this person, like with your 6 year old? Use Socratic questioning to gently create self doubt without triggering defensiveness. Things like what do you think makes someone truly powerful? Being admired or being trusted? What characteristic do the best leaders create in others? Fear or respect? And there's always something on LinkedIn about LE. Do you lead by fear? Do you lead by respect? So that's one of those that they probably thought about before. Or use the I wonder how, I wonder how they felt when this happened. Lot of people with NPD have that cognitive empathy or if maybe they got rejected for a job. Gee, I wonder how they came to that conclusion. If somebody reacts differently to a situation than they expect, you may say, I wonder how their history is different than yours. And, and it's causing them to perceive this behavior as threatening or aggressive. You know, so there's a lot of I wonder how I'm, I'm wondering what, where that's coming from. Use language that aligns with their self concept. Avoid terms like problem or weakness and instead use strategic awareness or self mastery. This is one that I have difficulty with. But um, it's just those aren't terms that just roll off of my tongue. We can say things like let's explore how to maximize your influence over situations like these. High performers like yourself often find it valuable to refine their strategies for different situations. Is that something you're interested in talking about or something as simple as I would be interested in your thoughts on this concept? If they start talking about how everyone out there always blames them, you know, I'd be interested in your thoughts on why that is. What are your thoughts on this concept? Leverage their desire without reinforcing grandiosity. Leverage their desire for influence or power and frame Emotional intelligence as an elite skill that enhances their ability to succeed and lead. It is. We're not blowing smoke here. It is, but we don't want to say, well, you suck at this. We want to say, you know, the more emotional intelligence you have, the more effective you may be at commanding control. So instead of saying, let's talk about your feelings, you can say, what issue is the greatest obstacle to your success right now? And what would it look like if that issue were resolved? That one of those issues ultimately is going to come back to lack of emotional intelligence. Finding those mutually agreeable goals is important for the person sitting in the patient's chair. It's, something's blocking me from my success. For me over here, it's, you don't understand that you have no emotional empathy or emotional intelligence. We both want the same thing. Once they develop more emotional intelligence, they're probably going to get towards their goals. We just have to come at it from a different perspective. Frame emotions as tools for personal success. Instead of let's explore your feelings of rejection, you can try something like emotional intelligence is a key factor in leadership. How do you read people's feelings in different settings or some of the pe? Most of influential people use emotional insight strategically. Have you ever considered that angle? Now that one is a little bit exploitive. Using emotions strategically feels exploitive to me. However, it may open the door so you can start talking about feelings more. Consider using third person perspective exercises before personalizing insights. So instead of asking about their emotions directly, start with a general case. Why do you think people sometimes react negatively to confidence? Or what's your take on why some leaders inspire loyalty while others generate resentment? Take out whatever they're going through. Why is it this happens sometimes? Not necessarily to you, but in these situations, if they engage with you, then gradually shift to the first person perspective. Has that ever happened to you? Introduce emotional depth through self enhancement. Instead of saying something like, you constantly manipulate people, you may say, it seems like you're highly skilled at managing impressions. Have you ever thought about how that impacts your deeper relationships? Or you clearly have a strong ability to influence people. What do you think when people experience when interacting with you, so that turns it back on them. What do you. What do you think people are experiencing when they're interacting with you? Trying to pull out that empathy a little bit more. Instead of saying your lack of empathy is damaging in your relationships, you can say, you have an impressive ability to stay rational in tough situations. Have you ever noticed moments where emotional insight could have given you an Even greater advantage. Encouraging them to weigh whether sometimes letting that emotion, emotional side, that empathy side come out might actually benefit them. Who knows? Use elite language to maintain engagement instead of saying your defenses are causing relationship issues. Again, that is me telling, that's me blaming. That's me taking their power. Not gonna work. We want to say high achievers sometimes have blind spots that limit their full potential. This is a great place where you could introduce the Johari window, where there's things that you know about you and other people know about you, things that other people know about you that you don't know about you, things that you know about you that nobody else knows and then things that nobody knows. And looking at what goes in each one of those windows can help with self mastery because it prevents them from being surprised, it prevents them from being caught off guard, which is something that goes into impression management and everything else. But it also starts helping them consider other perspectives. And finally, in terms of specific interventions, body based interventions or somatic interventions improve emotional regulation and frustration tolerance. Vagus nerve stimulation, either through deep breathing or trans oricular vagus nerve stimulation, where you wear the little clip on your ear that can help with vagus nerve stimulation. Biofeedback's another one. And a lot of people with NPD, because they like mastery and they like the challenge, really like biofeedback because it's almost a game to them to see, to develop mastery over their own nervous system and, and helping them learn how to do that, like we've talked about before, using a polar heart rate monitor and an app so they can see when their heart rate goes up and they can see how quickly they can bring it back down, that can be a challenge for them how whatever method they use to do that, by regularly activating that vagus nerve, either through transcutaneous methods or manually, if you will, it strengthens that parasympathetic tone and reduces the constant activity of the sympathetic nervous system. This can help calm things down in the body, which will be associated with reduced reactivity to perceived criticism, reduced hypervigilance, reduced irritability. Progressive muscular relaxation is another one that can be helpful when people are stressed, when they're on it, when they've got sympathetic dominance, their muscles stay a lot tighter, helping them relax their muscles so they can get better sleep and it will improve their overall energy levels. Increase structured self care routines, improve sleep and circadian rhythms. Circadian rhythm imbalances or alterations affect the stress response. When we're not, our circadian rhythms are imbalanced. Our stress Response goes kind of wonky too. We want to help them balance their circadian rhythms by creating routines and anchor points. Got a couple videos on that on the channel. And help them improve their quality of sleep. So they're going to sleep about the same time every night and they're getting good quality sleep. We really need to look at sleep hygiene. Sleep deprivation is associated with autonomic disregulation, dispiosis, hpa, AIs overactivation, inflammation and the consequent behavioral reactions that we often see in npd. And encourage them to consider an anti inflammatory gut healthy diet. This isn't a whole bunch of pro nutraceuticals or anything. This is just not having a lot of highly processed foods and making sure that you're eating foods that have probiotics and prebiotics in them. Probiotics like yogurt and prebiotics. Those are fibers, your soluble and insoluble fibers that you get from your vegetables. It's not really that hard. Developing reciprocity and social awareness. Use perspective taking exercises. Encourage them to role play or journal. Maybe have them act out situations from different perspectives or as different people. I want you to go through this situation with your significant other like Dr. Phil would have and then I want you to go through this situation with your significant other now. I want you to pretend to be Mother Teresa. Obviously they've got two very different approaches. You don't have to use those two people. Those were the only ones I could come up with. But you want to encourage them. At least one of the people they act out is going to be somebody that is polar different than them in terms of empathy and emotionality. You can have them try journaling from a different age. Write about this as if you were a six year old and then write about this as if you were a an 80 year old person. Reflecting on your life delayed response training helps reduce impulsive reactions. Encourage people before responding to a conflict, think about three possible interpretations of the other person's behavior. Or before responding to a conflict or making a decision, ask yourself what are the long term effects of this choice five years from now? Encourage boundary setting work respecting without resentment. A lot of people with NPD have difficulty not resenting others when other people set boundaries. Because when I set a boundary I'm taking their control the way I'm not letting them control me like a marionette. And that's very threatening to them. So we want to help them work on boundary setting without resentment. What does respect mean to you in relationships? What does it look like, how do you know when a boundary is being set fairly? If this person sets a boundary, but the boundary is overreaching in some way, then maybe that's not a fair boundary. But let's talk about what that looks like. Remind them resentment's a form of anger. I'm wondering why it makes you angry when people set boundaries. Now, that's an advanced question. Because we're encouraging them or we're asking them to think about a feeling here. But as we get to this place, it is something we can ask. And if they back away, all right, you know, I'm not going to push it. But if they're willing to explore it, then that's great. We want to help increase distress tolerance and reduce disregulation. Say things like, I can only imagine how frustrating it is every day to deal with other people's mistakes and shortcomings. I'm wondering how you might be able to adjust your response so it doesn't wear you down as much. Acknowledging that nobody's perfect and acknowledging that other people's imperfections wear them down because that's where they focus their energy and their attention not on what did what I did wrong, but what everybody else around me did wrong because I can't look at my own weaknesses or shortcomings. Encourage shame. Resilience training. Reframing mistakes as learning opportunities, not personal failures. All right, you relapsed. What can we learn from that that can help you refine your strategy for the next time? You can also ask, can you recall a time when feedback helped you improve, and how did you use it to your advantage in terms of challenging rigid thought patterns? Use cognitive restructuring. You may say something like, as a parent and a leader, I'm sure there have been times when your expectations weren't met. How did you adjust during those times and after? They answer, in retrospect, are there other ways you could have adjusted to better achieve your goal? And a lot of times, especially if they've got children at home, this may be one of those questions that you can get a lot of traction on. Because the child didn't meet their expectations, they may have adjusted and the child still didn't meet their expectations. It just kind of blew up. So in retrospect, how might we be able to refine your strategy in order to help you help them meet your expectations? Focus on intrinsic rewards rather than external validation. What is it about doing this that makes you feel good? That makes you feel worthy? Identify and address external triggers for anger and frustration. Ask things like what internal qualities make you feel successful beyond how others react and recognize external triggers. If it's certain people or being in certain situations, people may feel more hyper vigilant and triggered in a meeting if somebody criticizes them than if it's one on one. I think a lot of us feel that way. If we get thrown under the bus, we tend to get more defensive and, you know, bow up a little bit. Encourage them to figure out how to reduce high stress environments and routines to reduce stress reactivity. Identify those environments that typically end up with the person blowing up or things not going well or them storming out and figure out, okay, what is it about those environments that tend to end badly and how can we refine your strategy? Always come back to refining the strategy and enhancing your skills to move towards your goals. Treating NPD requires a nuanced approach that respects the client's need for control while enhancing their self awareness, emotion regulation, and interpersonal reciprocity. Intervention should target physiological disregulation, entitlement, frustration and distress tolerance, self esteem regulation, keeping it, you know, moderated, and impulsivity. Understanding NPD through the Pieces Framework Physical, interpersonal, emotional, cognitive, and Environmental highlights its multifactorial origins, including neurobiological vulnerabilities, early relational experiences, emotional dysregulation, and cognitive distortions.