Any Information on ACoA being Misdiagnosed as Bipolar?
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Q:  Any Information on ACoA being Misdiagnosed as Bipolar?

Hi Dr. Phelps!
Thanks in advance for your time. I was recently diagnosed with bipolar I disorder with anxiety problems. My psych recommended a combination of lamotrigine and ativan. This is my second time going to a psychiatrist; they both have come up with the same diagnosis, which somehow in my head makes things seemingly more concrete. However, recently I was reading about adult children of alcoholics. As a child raised in an alcoholic home, I read the characteristics of an ACA, and everything immediately clicked. As I was reading, I couldn't help but think, "This is totally me."
Anyhow, my concern is that the characteristics of bipolar disorder and ACA's seem awfully similar. Have you heard anything about ACA's being misdiagnosed as bipolar? I would really appreciate any help you can give me, as neither my psych nor my therapist nor my ACA group leader really seem to have much information on BOTH these areas. Thanks!

Dear V’ –

Well, let's look at the characteristics of each, lined up alongside one another, looking for similarities (I took the list for the adult child of an alcoholic (ACoA) from one of the larger websites on the topic, at

In the table below, I agree that the first six items have so much overlap, it would be difficult to differentiate between the two.  Compare them, item for item, left column versus right. 


ACoA Bipolarity

1.      trouble having fun

2.      judging oneself “without mercy”

3.      no follow-through

4.      impulsive then locked in to choices

5.      overreaction

6.      take self seriously

·         lying

·         intimacy problems

·         seek approval

·         loyal, to a fault

o   responsible/irresponsible

o   uncertain: Am I normal? different?


1.      depression (including #2 below)

2.      extreme self-deprecation or hatred

3.      distractible

4.      impulsive, imprudent choices

5.      elated, expansive or irritable

6.      grandiosity

·         decreased need for sleep; insomnia

·         flight of ideas / racing thoughts

·         increased activity levels

·         pressured speech


Not much overlap in the items after number six, correct?  Remember, of course, that in bipolar disorder, these characteristics are supposed to come and go, or fluctuate somehow at least, if they don't overtly "cycle".  By contrast, presumably the ACoA would demonstrate these traits all the time, or close.

Remember also that in bipolar disorder, people are supposed to go through phases where they "don't feel like their usual self": there should be an unequivocal change in functioning. During those times, the changes in them should be observable by others, according to the official criteria. 

Many mood specialists believe that there is a major exception to these requirements in people with continuous "mixed states", who never have a phase of "normal" to which they could compare and look for unequivocal change in functioning (here’s the best description of that view of mixed states I know of).  If you remove this requirement of obvious phases of “unequivocal change in functioning, observable by others", then differentiating other conditions which have similar symptoms becomes much more difficult. 

Under these circumstances I generally recommend that less emphasis be placed on trying to get the "right diagnosis", and instead, more emphasis placed on considering what treatment options might be pulled out for each of the two possible diagnoses.  Often times, looking at the treatment options is much simpler and straightforward.

For example, if the ACoA paradigm fits very closely, why not attend an ACoA group? Even if you're wrong (you do indeed have bipolar disorder), it might help anyway. And it probably won't make things worse, if you did instead have bipolar disorder.  Unless you waste too much time getting totally religious about it, I suppose.  Granted, some people do that with a diagnosis of bipolar disorder, as well as with the model of ACoA as an explanation for their struggles.

By contrast, if you have symptoms that are severe enough to warrant a medication approach, you probably have exceeded the margins of the ACoA concept, e.g. severe depression: by definition, that would either be a "major depression", or bipolar depression. Obviously you could have that on top of the ACoA problems, but the treatment in this case would be targeting these severe mood symptoms that are not explained by the ACoA concept. In that case, you face the same dilemma that anyone with depression faces: presuming that other causes like thyroid hormones being too low have been considered and ruled out, is your mood problem major depression, or bipolar disorder?  The reason for that question is because there is a dramatic difference in the treatment approach, where the treatment for one can actually make the other worse (antidepressants, that is).

So, perhaps the simple answer is this: a person may indeed struggle because of their ACoA history.  But if their struggle is so severe as to compromise their ability to function, and make for "observable changes" that others can recognize, then such a person may be having symptoms that go beyond what ACoA can explain.  Or at least, such a person is in a position to consider medication approaches, as well as psychotherapy, for those symptoms.  At that point, when medications are considered, then one must choose whether or not to use an antidepressant.  Then the determination of "bipolar, or not?"  finally needs to be made.

I hope that might help you and the group somewhat.  Not a definitive answer, but I'm not aware of anything more data-based.

Dr. Phelps

Published January, 2009


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