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This article briefly summarizes the empirical and clinical literature underlying a contemporary clinical model of pathological narcissism. Unlike the DSM Narcissistic Personality Disorder (NPD), this clinical model identifies and differentiates between two phenotypic themes of dysfunction—narcissistic grandiosity and narcissistic vulnerability—that can be expressed both overtly and covertly in patients' ways of thinking, feeling, behaving, and participating in treatment. Clinical recognition that narcissistic patients can and often do present for psychotherapy in vulnerable states of depression, anxiety, shame, and even suicidality increases the likelihood of accurate diagnosis and effective treatment planning. This article provides case examples derived from psychotherapies with narcissistic patients to demonstrate how narcissistic grandiosity and narcissistic vulnerability concurrently present in patients who seek treatment.