A 26-year-old African-American single woman is seen in the outpatient clinic with her mother. She is dressed provocatively and s
tates that she is Whitney Houston's daughter and a very important person who knows many famous actors. Her thought content is significant for thought blocking. At times, she is observed to direct her attention to random parts of the room, presumably as a result of active auditory hallucinations. She also believes that everything that she thinks will, in fact, happen. The patient reports that she has always been shy, with few or no friends as she grew up. She started to experience perceptual disturbances around the age of 18 when she "saw spirits but did not hear them." Around that time she also became aware of her ability to know the future. For example, once she looked toward the airport and knew that 2 planes would crash in the future. She wanted to call someone to report it but did not know whom to call. Days later there were 2 accidents. Despite such unusual experiences, she was able to train as a dental technician and had a steady job for 5 years. During that time, she started to experience more auditory hallucinations. She described them as voices conversing, at times yelling or giving her directions, even telling her to kill herself, when under stress. She also reported that she resisted the voices by distracting herself, as she did not want to die. Last year she also had a mixed episode, during which she was manic, did not sleep for more than a week, felt "hyper," impulsive, and "tingling," and also depressed. At that time she decided that she could not continue to work in the same place and left; she has not since held a job. At the time of her initial evaluations, she was living with her parents and brother. About 1 year ago, she started an antipsychotic medication, which decreased the intensity of the voices and the fear that other people could read her thoughts. During the past year, she has had manic symptoms most of the time (including grandiosity, impulsivity, decreased sleep, and mixed mood symptoms). This culminated with an exacerbation about 6 months ago that prompted psychiatric hospitalization. On examination, she was sitting in a somewhat provocative position on the couch. Her speech was high-pitched. She appeared relaxed, although at random times she would get tense. Her thought process was slow and tangential, with intermittent thought blocking. Her attention span was moderately diminished. No active suicidal or homicidal thoughts were present; however, she reported that the voices insisted that she should jump out of the window. Her insight and judgment were poor.
What diagnosis best fits?
