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Bipolar disorder (BD) is characterized by speech abnormalities, reflected by symptoms such as pressure of speech in mania and poverty of speech in depression. Here we aimed at investigating speech abnormalities in different episodes of BD, including mixed episodes, via process-oriented measures of verbal fluency performance – i.e., word and error count, semantic and phonological clustering measures, and number of switches–, and their relation to neurocognitive mechanisms and clinical symptoms. 93 patients with BD – i.e., 25 manic, 12 mixed manic, 19 mixed depression, 17 depressed, and 20 euthymic–and 31 healthy controls were administered three verbal fluency tasks – free, letter, semantic–and a clinical and neuropsychological assessment. Compared to depression and euthymia, switching and clustering abnormalities were found in manic and mixed states, mimicking symptoms like flight of ideas. Moreover, the neuropsychological results, as well as the fact that error count did not increase whereas phonological associations did, showed that impaired inhibition abilities and distractibility could not account for the results in patients with manic symptoms. Rather, semantic overactivation in patients with manic symptoms, including mixed depression, may compensate for trait-like deficient semantic retrieval/access found in euthymia.“For those who are manic, or those who have a history of mania, words move about in all directions possible, in a three-dimensional ‘soup’, making retrieval more fluid, less predictable.”  Kay Redfield Jamison (2017, p. 279).

Thought and language disturbance in bipolar disorder quantified via process-oriented verbal fluency measures