Mental Illness in Adults With Fetal Alcohol Syndrome or Fetal Alcohol Effects

Subjects living in the western part of the state of Washington were selected from a large, ongoing study of individuals with fetal alcohol syndrome or fetal alcohol effects in progress at the University of Washington Fetal Alcohol and Drug Unit. Subjects were diagnosed by dysmorphologists over a 21-year period (4). Fetal alcohol syndrome is characterized by growth deficiency, a pattern of dysmorphic facial features, and some manifestation of CNS dysfunction. Subjects who had some but not all of the characteristics of fetal alcohol syndrome were diagnosed as having fetal alcohol effects. All subjects had significant prenatal alcohol exposure. As used here, the term “fetal alcohol effects” is comparable to the more recent term of “alcohol-related neurodevelopmental disorder” (7).

Only subjects older than 18 years and only subjects with an IQ higher than 70 were eligible to participate in the structured clinical interview. The IQ criterion excluded approximately 9% of otherwise eligible individuals. Of the 51 subjects who met final criteria, 14 had no telephone, three refused to participate, and nine could not be seen because of scheduling problems. The final study group (N=25) included 11 subjects with fetal alcohol syndrome (six men and five women) and 14 with fetal alcohol effects (nine men and five women). The subjects' mean age was 28.8 (range=19–51), and their mean IQ was 86.6 (range=73–110). After a complete description of the study, written informed consent was obtained from all subjects. The diagnostic interview was then conducted in the subject's home. A comparison of the 25 subjects who were interviewed with the 26 who were eligible but not interviewed revealed no statistically significant differences in terms of age, sex, race, or diagnosis of fetal alcohol syndrome or fetal alcohol effects.

The mental health evaluations were conducted by a medical student (C.F.) using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) (5) and the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) (6). The SCID and SCID-II are structured clinical interviews used to diagnose and document the major axis I and axis II disorders of adolescents and adults according to criteria set by APA. Training in the administration and scoring of the SCID and SCID-II was overseen by the University of Washington Psychiatry Outpatient Clinic in Seattle. A psychiatrist consulted regarding SCID and SCID-II DSM-IV and DSM-III-R diagnoses. The SCID and SCID-II interviews were scored according to criteria, and the descriptive data are presented.

Of the 25 subjects evaluated, 23 received an axis I diagnosis (table 1). Fifteen of the study subjects met criteria for current or past alcohol or drug dependence. The second most common axis I disorder was depression: 11 subjects had experienced a major depressive episode, past or present. The third most common group of axis I diagnoses was psychotic disorders: 10 subjects reported psychotic symptoms, and the most common type of psychotic diagnosis was brief psychotic disorder (N=7). Of the remaining individuals with psychotic disorders, one subject was diagnosed with schizoaffective disorder, one with delusional disorder, and one with psychotic disorder not otherwise specified. Bipolar I and anxiety disorders were each diagnosed in five of the subjects interviewed. Some subjects with anxiety disorders had more than one type of anxiety diagnosis. This included four diagnosed with posttraumatic stress disorder, two with panic disorder, one with generalized anxiety disorder, and one with a specific phobia (claustrophobia). Eating disorders were identified by the SCID in four subjects; two of these individuals had binge eating, one had anorexia nervosa, and one had bulimia nervosa. One subject was diagnosed with dysthymic disorder.

The SCID-II (based on DSM-III-R criteria) was administered to 21 of the 25 subjects. Ten subjects were diagnosed as having a personality disorder. The most common axis II diagnoses were avoidant personality disorder (N=6), antisocial personality disorder (N=4), and dependent personality disorder (N=3); one subject each had paranoid, schizotypal, and borderline personality disorder.

A high proportion of the subjects had received mental health services. According to self-report, 18 of the 25 subjects received some form of psychiatric treatment, and six of these required hospitalization in a psychiatric institution.

These results indicate that individuals with fetal alcohol syndrome or fetal alcohol effects manifested clinically significant mental illness as they matured and that most used some form of counseling or psychiatric treatment. Caution must be exercised in interpreting the results, however. The number of subjects studied was small. A small number of individuals who were mentally retarded were excluded because of SCID and SCID-II administration criteria; other techniques would be needed to evaluate their mental health. In addition, many patients in the Fetal Alcohol Follow-Up Study were originally referred for diagnostic evaluations because of adaptational difficulties. This type of recruitment selects against individuals with fetal alcohol syndrome or fetal alcohol effects who are experiencing minor or no difficulties.

To our knowledge, this is the first published study of psychiatric diagnoses in adults with fetal alcohol syndrome or fetal alcohol effects. We found a high risk of psychopathological conditions in these adults. Although it would not have been surprising to find elevated alcohol and drug-related psychopathology in these subjects, the fact that 15 of 25 subjects were diagnosed with alcohol or drug dependence is striking. Similarly, the rate of major depression was surprisingly high, and, in contrast to studies of subjects without fetal alcohol syndrome or fetal alcohol effects, the rate of depression was nearly equal among men and women. Several reports (8–10) have suggested that gestational brain injury is associated with the subsequent development of psychotic symptoms and that premature exposure to alcohol is a possible etiology of schizophrenia. Although the rate of psychosis was high in our subjects, the diagnosis of schizophrenia was not made in any individual in this small study group. Examination of the relationship between gestational alcohol exposure and subsequent mental illness in a population-based sample would be an important next step. Ultimately, such efforts should lead to a more deliberate, prospective allocation of clinical resources for individuals with fetal alcohol syndrome or fetal alcohol effects.

Presented in part at the Annual Meeting of the Research Society on Alcoholism, Washington, D.C., June 22–27, 1996. Received June 16, 1997; revision received Sept. 12, 1997; accepted Oct. 3, 1997. From the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Streissguth, Box 359112, University of Washington, Seattle, WA 98195. Funded by grant R04/CCR-008515 from the Centers for Disease Control Prevention (Dr. Streissguth), the University of Washington Medical Student Research Fund, and the Seattle Foundation. The authors thank Deborah Cowley, M.D., and James O'Connel for supervising the administration of the structured clinical interview; Sterling Clarren, M.D., for being the primary diagnostician for fetal alcohol syndrome or fetal alcohol effects; and Helen Barr, M.A., M.S., for database retrievals and sample selection.