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,
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.
trouble having fun
judging oneself “without mercy”
impulsive then locked in to choices
take self seriously
loyal, to a fault
uncertain: Am I normal? different?
depression (including #2 below)
extreme self-deprecation or hatred
impulsive, imprudent choices
elated, expansive or irritable
decreased need for sleep; insomnia
flight of ideas / racing thoughts
increased activity levels
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
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
I hope that might help you and the group somewhat. Not a definitive answer,
but I'm not aware of anything more data-based.
Published January, 2009