Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion 83). Individ- uals may talk continuously and without regard for others’ wishes to communicate, often in an intrusive manner or without concern for the relevance of what is said. Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of speech often become more important than what is conveyed. If the individual’s mood is more irritable than expansive, speech may be marked by complaints, hostile comments, or angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion
A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., de- pressive) pole (see ”with mixed features" specifier, pp. 149—150).
Often the individual’s thoughts race at a rate faster than they can be expressed through speech (Criterion B4). Frequently there is ﬂight of ideas evidenced by a nearly continuous ﬂow of accelerated speech, with abrupt shifts from one topic to another. When ﬂight of ideas is se- vere, speech may become disorganized, incoherent, and particularly distressful t0 the individ- ual. Sometimes thoughts are experienced as so crowded that it is very difficult to speak.
Distractibility (Criterion BS) is evidenced by an inability to censor immaterial external stimuli (e.g., the interviewer’s attire, background noises or conversations, furnishings in the room) and often prevents individuals experiencing mania from holding a rational con— versation or attending to instructions.
The increase in goal-directed activity often consists of excessive planning and partici- pation in multiple activities, including sexual, occupational, political, or religious activi- ties. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often display psychomotor agitation or rest- lessness (i.e., purposeless activity) by pacing or by holding multiple conversations simulta- neously. Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media.
The increased activity criterion can be difficult to ascertain in children; however, when the child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations (not accounted for by sexual abuse or exposure to sexually explicit mate— rial), then Criterion B might be met based on clinical judgment. It is essential to determine whether the behavior represents a change from the child’s baseline behavior; occurs most of the day, nearly every day for the requisite time period; and occurs in temporal associa- tion with other symptoms of mania.
The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless involvement in activities such as spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have catastrophic consequences (Criterion B7). The individual may purchase many unneeded items without the money to pay for them and, in some cases, give them away. Sexual behavior may include infidelity or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually transmitted diseases or interpersonal consequences.
The manic episode must result in marked impairment in social or occupational func- tioning or require hospitalization to prevent harm to self or others (e.g., financial losses, i1- legal activities, loss of employment, self—injurious behavior). By definition, the presence of psychotic features during a manic episode also satisfies Criterion C.