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Alice in Wonderland syndrome
Other names Todd's syndrome, Lilliputian hallucinations, dysmetropsia
The perception a person can have due to micropsia, a potential symptom of dysmetropsia. From Lewis Carroll's 1865 novel Alice's Adventures in Wonderland
Specialty Psychiatry, neurology
Symptoms
  • Macropsia - Objects are perceived larger than their actual size
  • Micropsia - Objects are perceived smaller than their actual size
  • Pelopsia - Objects are perceived nearer than they actually are
  • Teleopsia - Objects are perceived much further away than they are
  • Metamorphopsia - Altered perception of shape
  • Tachysensia - Altered perception of time
Complications Impaired vision
Usual onset Before, during, or after a migraine [1]
Duration Each symptom is separate and will only occur for a 20-to-50-minute period.

Alice in Wonderland syndrome (AIWS), also known as Todd's syndrome or dysmetropsia, is a neurological disorder that distorts perception. People with this syndrome may experience distortions in their visual perception of objects, such as appearing smaller (micropsia) or larger (macropsia), or appearing to be closer (pelopsia) or farther (teleopsia) than they are. Distortion may also occur for senses other than vision.

Classification copied from Alice in Wonderland syndrome

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The classification is not universally agreed upon in literature, however, some authors distinguish true Alice in Wonderland syndrome based solely on symptoms related to alterations in a person's body image. The classification of these symptoms were first introduced in 1955, which migraines were the most adimate symtpom that followed with illusions, feeling smaller microsomatognosia, and feeling macrosomatognosia than usual. [2]In contrast, they utilize the term "Alice in Wonderland-like syndrome" to encompass symptoms associated with changes in perception of vision, time, hearing, touch, or other external perceptions.[3][4]

Due to the classification of all the clinical features seen in Alice in Wonderland, the table below illustrates theses features and symptoms by type with Type C having a combination of Type A and Type B symptoms.[2]

Types Obligatory symptoms Facultative symptoms
Type A Aschematia: partial or total macrosomatognosia or microsomatognosia; paraschematia Derealization, depersonalization, somatopsychic duality, aberration in judgement of time
Type B Macro- and micropsia and/or tele- and pelopsia. When micropsia and telopsia appear at the same time and for the same object: porropsia

Lilliputianism (people appearing smaller)

Type C Type A + type B symptoms


Prognosis copied from Alice in Wonderland syndrome

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The symptoms of Alice in Wonderland syndrome themselves are not inherently harmful and are often not frightening to the experiencer. Since there is no established treatment for Alice in Wonderland syndrome, prognosis varies between patients and is based on whether an underlying cause has been identified.[5] In many cases, the intensity of the episodes and symptoms decline. Since it is predominately a benign and non-harmful condition, treatment isn't always required. Some cases include reoccurring symptoms in which other medical conditions have to be ruled out before diagnosing AIWS [6]Limitations of Alice in Wonderland syndrome are due to the rarity of having the disorder, making this rare syndrome under diagnosed due to its rarity. Due to the rarity, symptoms needs got be closely evaluated and observed by a professional [7]

If Alice in Wonderland Syndrome is caused by underlying conditions, symptoms typically occur during the underlying disease and can last from few days to months.[8] In most cases, symptoms may disappear either spontaneously, with the treatment of underlying causes, or after reassurances that symptoms are momentary and harmless.[9] In some cases it is experienced no more than a few episodes of symptoms, in other cases, symptoms may repeat several episodes before resolve. In rare cases, symptoms continue to manifest years after the initial experience, sometimes with the development of new visual disorders or migraines.[5] These manaifestations and disortions is why medication is then introduced but have some inducing effects [10]

Treatment copied from Alice in Wonderland syndrome

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At present (2024), Alice in Wonderland Syndrome has no standardized treatment plan.[11] Test including eectroencephalogram (EEG) and magnetic resonance imaging (MRI) are used to view brain aciitvity to examine possible brain injury or deficits.[12] Since symptoms of Alice in Wonderland syndrome often disappear, either spontaneously on their own, or with the treatment of the underlying disease, most clinical and non-clinical Alice in Wonderland Syndrome cases are considered to be benign. In cases of Alice in Wonderland syndrome caused by underlying chronic disease, however, symptoms tend to reappear during the active phase of the underlying cause (e.g., migraine, epilepsy). If treatment of Alice in Wonderland Syndrome is determined necessary and useful, it should be focused on treating the suspected underlying disease. Treatment of these underlying conditions mostly involves prescription medications such as antiepileptics, migraine prophylaxis, antivirals, anxiolytics [12] , or antibiotics. Antipsychotics are rarely used in treating Alice in Wonderland Syndrome symptoms due to their minimal effectiveness.[13]. Unfortunately, there are also rare cases in which these prescription medications. specifically antipsychotics. may worsen psychosis and psychotic symptoms due to the severity of distortions. [10]

In 2011, a patient was examined for having verbal auditory hallucinations (VAHs) and functional MRI (fMRI) was employed to localize cerebral activity during self-reported VAHs. Repetitive transcranial magnetic stimulation (rTSMS) was used on the patient's Brodmann's area 40, in charge of meaning and phonology, at a frequency of 1 Hz at T3P3. After the second week of treatment, all VAHs and sensory distortions have no effected on the patient and went through a full remission. Follow up appointments were conducted with no signs of any symptoms. By month 8, the symptoms returned. A second treatment was done with complete remission. [14]

Depersonalization/derealization. copied from Alice in Wonderland syndrome

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Along with these size, mass, and shape distortions of the body, those with Alice in Wonderland syndrome often experience a feeling of disconnection from one's own body, feelings, thoughts, and environment.[15] Depersonalization is a term spefically used to express a true distachment from their persanol self's and identity. It's described as being an observer completely outside of their own actions and behaviors. Derealization is seen as “dreamlike, empty, lifeless, or visually distorted.[16] Drug and alchol use can exacerabte this symptom into psychosis.


Visual distortions

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Individuals with AIWS can experience illusions of expansion, reduction, or distortion of their body image, such as microsomatognosia (feeling that their own body or body parts are shrinking), or macrosomatognosia (feeling that their body or body parts are growing taller or larger). These changes in perception are collectively known as metamorphopsias, or Lilliputian hallucinations,[17] which refer to objects appearing either smaller or larger than reality.[18] People with certain neurological diseases may also experience similar visual hallucinations.[19]

Within the category of Lilliputian hallucinations, people may experience either micropsia or macropsia. Micropsia is an abnormal visual condition, usually occurring in the context of visual hallucination, in which the affected person sees objects as being smaller than they are in reality.[20] Macropsia is a condition where the individual sees everything larger than it is.[21] These visual distortions are sometimes classified as "Alice in Wonderland-like syndrome" instead of true Alice in Wonderland syndrome but are often still classified as Alice in Wonderland syndrome by health professionals and researchers since the distinction is not official.[22][23] Other distortions include teleopsia, objects are perceived further than they actually are, and pelopsia, objects are percieved closer than they actually are. [24] Gulliver's syndrome,

It was reported, by Lanska and Lanska (2013), that of all clinical cases, "Some 85% of patients present with perceptual distortions in a single sensory modality, e.g., only visual or only somesthetic. Moreover, the majority experience only a single type of distortion, e.g., only micropsia or only macropsia."[25]


Migraines[edit]

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1 in 10 people who experience migraines have symptoms of Alice in Wonderland syndrome. [24]The role of migraines in Alice in Wonderland syndrome is still not understood, but both vascular and electrical theories have been suggested. For example, visual distortions may be a result of transient, localized ischemia in areas of the visual pathway during migraine attacks. In addition, a spreading wave of depolarization of cells (particularly glial cells) in the cerebral cortex during migraine attacks can eventually activate the trigeminal nerve's regulation of the vascular system. The intense cranial pain during migraines is due to the connection of the trigeminal nerve with the thalamus and thalamic projections onto the sensory cortex. Alice in Wonderland syndrome symptoms can precede, accompany, or replace the typical migraine symptoms. Typical migraines (aura, visual derangements, hemicrania headache, nausea, and vomiting) are both a cause and an associated symptom of Alice in Wonderland Syndrome. Alice in Wonderland Syndrome is associated with macrosomatognosia which can mostly be experienced during migraine auras.

References

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Blom, Jan Dirk (June 6, 2016). "Alice in Wonderland syndrome". Neurology Clinical Practice - American Academy of Neurology: 259–270.

Murphy, Rachael J. (Jan.-March 20, 2023). "Depersonalization/Derealization Disorder and Neural Correlates of Trauma-related Pathology: A Critical Review". Innovations of Clinical Neuroscience: 53–59.

Mastria, Giulio; Mancini, Valentina; Viganò, Alessandro; Di Piero, Vittorio (2016). "Alice in Wonderland Syndrome: A Clinical and Pathophysiological Review". BioMed Research International. 2016: 1–10. doi:10.1155/2016/8243145. ISSN 2314-6133. PMC 5223006. PMID 28116304.

Palacios-Sánchez, Leonardo; Botero-Meneses, Juan Sebastián; Mora-Muñoz, Laura; Guerrero-Naranjo, Alejandro; Moreno-Matson, María Carolina; Pachón, Natalia; Charry-Sánchez, Jesús David (April–June 2018). "Alice in Wonderland Syndrome (AIWS). A reflection". Colombian Journal of Anesthesiology. 46 (2): 143. doi:10.1097/CJ9.0000000000000026. ISSN 2256-2087.

Woffindin, Louise (2023-04-03). "All about Alice in Wonderland Syndrome". CPD Online College. Retrieved 2024-04-28.

"Alice in Wonderland syndrome: a strange visual perceptual disturbance". psychiatry-psychopharmacology.com. doi:10.1080/24750573.2017.1354655. Retrieved 2024-04-28.


(Removed WebMD citation off of AIWS chart that was liked to the symptom of migraines and replaced it with [26])

  1. ^ Mastria, Giulio; Mancini, Valentina; Viganò, Alessandro; Piervincenzi, Claudia; Petsas, Nikolaos; Puma, Marta; Giannì, Costanza; Pantano, Patrizia; Di Piero, Vittorio (2023). "Neuroimaging markers of Alice in Wonderland syndrome in patients with migraine with aura". Frontiers in Neurology. 14. doi:10.3389/fneur.2023.1210811/full#:~:text=background:%20the%20alice%20in%20wonderland,associated%20with%20migraine%20in%20adults.. ISSN 1664-2295. {{cite journal}}: Check |doi= value (help)
  2. ^ a b Mastria, Giulio; Mancini, Valentina; Viganò, Alessandro; Di Piero, Vittorio (2016). "Alice in Wonderland Syndrome: A Clinical and Pathophysiological Review". BioMed Research International. 2016: 1–10. doi:10.1155/2016/8243145. ISSN 2314-6133.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  3. ^ Lanska, Douglas J.; Lanska, John R. (2018), Bogousslavsky, J. (ed.), "The Alice-in-Wonderland Syndrome", Frontiers of Neurology and Neuroscience, 42, S. Karger AG: 142–150, doi:10.1159/000475722, ISBN 978-3-318-06088-1, PMID 29151098, retrieved 2021-07-27
  4. ^ Podoll, K.; Ebel, H.; Robinson, D.; Nicola, U. (2002). "[Obligatory and facultative symptoms of the Alice in wonderland syndrome]". Minerva Medica. 93 (4): 287–293. ISSN 0026-4806. PMID 12207198.
  5. ^ a b Liu, Alessandra M.; Liu, Jonathan G.; Liu, Geraldine W.; Liu, Grant T. (2014). ""Alice in Wonderland" Syndrome: Presenting and Follow-Up Characteristics". Pediatric Neurology. 51 (3): 317–320. doi:10.1016/j.pediatrneurol.2014.04.007. ISSN 0887-8994. PMID 25160537.
  6. ^ Palacios-Sánchez, Leonardo; Botero-Meneses, Juan Sebastián; Mora-Muñoz, Laura; Guerrero-Naranjo, Alejandro; Moreno-Matson, María Carolina; Pachón, Natalia; Charry-Sánchez, Jesús David (April–June 2018). "Alice in Wonderland Syndrome (AIWS). A reflection". Colombian Journal of Anesthesiology. 46 (2): 143. doi:10.1097/CJ9.0000000000000026. ISSN 2256-2087.{{cite journal}}: CS1 maint: date format (link)
  7. ^ Blom, Jan Dirk (2016-06). "Alice in Wonderland syndrome". Neurology Clinical Practice. 6 (3): 259–270. doi:10.1212/cpj.0000000000000251. ISSN 2163-0402. {{cite journal}}: Check date values in: |date= (help)
  8. ^ O'Toole P, Modestino EJ (2017). "Alice in Wonderland Syndrome: A real-life version of Lewis Carroll's novel". Brain & Development. 39 (6): 470–474. doi:10.1016/j.braindev.2017.01.004. PMID 28189272. S2CID 3624078.
  9. ^ Blom, Jan Dirk (2016). "Alice in Wonderland syndrome". Neurology: Clinical Practice. 6 (3): 259–270. doi:10.1212/CPJ.0000000000000251. ISSN 2163-0402. PMC 4909520. PMID 27347442.
  10. ^ a b Blom, Jan Dirk (2016-06). "Alice in Wonderland syndrome". Neurology Clinical Practice. 6 (3): 259–270. doi:10.1212/cpj.0000000000000251. ISSN 2163-0402. {{cite journal}}: Check date values in: |date= (help)
  11. ^ O'Toole, Patrick; Modestino, Edward (2017). "Alice in Wonderland Syndrome: A real-life version of Lewis Carroll's novel". Brain and Development. 39 (6): 470–474. doi:10.1016/j.braindev.2017.01.004. ISSN 0387-7604. PMID 28189272. S2CID 3624078.
  12. ^ a b "Alice in Wonderland syndrome: a strange visual perceptual disturbance". psychiatry-psychopharmacology.com. doi:10.1080/24750573.2017.1354655. Retrieved 2024-04-28.
  13. ^ Blom, Jan Dirk (2016). "Alice in Wonderland syndrome". Neurology: Clinical Practice. 6 (3): 259–270. doi:10.1212/CPJ.0000000000000251. ISSN 2163-0402. PMC 4909520. PMID 27347442.
  14. ^ Blom, Jan Dirk; Looijestijn, Jasper; Goekoop, Rutger; Diederen, Kelly M.J.; Rijkaart, Anne-Marije; Slotema, Christina W.; Sommer, Iris E.C. (2011). "Treatment of Alice in Wonderland Syndrome and Verbal Auditory Hallucinations Using Repetitive Transcranial Magnetic Stimulation: A Case Report with fMRI Findings". Psychopathology. 44 (5): 337–344. doi:10.1159/000325102. ISSN 0254-4962.
  15. ^ Lanska, Douglas J.; Lanska, John R. (2018), Bogousslavsky, J. (ed.), "The Alice-in-Wonderland Syndrome", Frontiers of Neurology and Neuroscience, 42, S. Karger AG: 142–150, doi:10.1159/000475722, ISBN 978-3-318-06088-1, PMID 29151098, retrieved 2021-07-27
  16. ^ Büetiger, Jessica R.; Hubl, Daniela; Kupferschmid, Stephan; Schultze-Lutter, Frauke; Schimmelmann, Benno G.; Federspiel, Andrea; Hauf, Martinus; Walther, Sebastian; Kaess, Michael; Michel, Chantal; Kindler, Jochen (2020-09-11). "Trapped in a Glass Bell Jar: Neural Correlates of Depersonalization and Derealization in Subjects at Clinical High-Risk of Psychosis and Depersonalization–Derealization Disorder". Frontiers in Psychiatry. 11. doi:10.3389/fpsyt.2020.535652. ISSN 1664-0640.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  17. ^ Farooq O, Fine EJ (2017). "Alice in Wonderland Syndrome: A Historical and Medical Review". Pediatric Neurology. 77: 5–11. doi:10.1016/j.pediatrneurol.2017.08.008. PMID 29074056.
  18. ^ Craighead WE, Nemeroff CB, eds. (2004). "Hallucinations". The Concise Corsini Encyclopedia of Psychology and Behavioral Science. Hoboken: Wiley. ISBN 978-0-471-22036-7.
  19. ^ "Alice in Wonderland syndrome". Mosby's Dictionary of Medicine, Nursing & Health Professions. Philadelphia: Elsevier Health Sciences. 2009. ISBN 978-0-323-22205-1.
  20. ^ "Micropsia". Mosby's Emergency Dictionary. Philadelphia: Elsevier Health Sciences. 1998.
  21. ^ "Macropsia". Collins English Dictionary. London: Collins. 2000. ISBN 978-0-00-752274-3. Archived from the original on 2018-01-07.
  22. ^ Lanska, Douglas J.; Lanska, John R. (2018), Bogousslavsky, J. (ed.), "The Alice-in-Wonderland Syndrome", Frontiers of Neurology and Neuroscience, 42, S. Karger AG: 142–150, doi:10.1159/000475722, ISBN 978-3-318-06088-1, PMID 29151098, retrieved 2021-07-27
  23. ^ Podoll, K.; Ebel, H.; Robinson, D.; Nicola, U. (2002). "[Obligatory and facultative symptoms of the Alice in wonderland syndrome]". Minerva Medica. 93 (4): 287–293. ISSN 0026-4806. PMID 12207198.
  24. ^ a b Woffindin, Louise (2023-04-03). "All about Alice in Wonderland Syndrome". CPD Online College. Retrieved 2024-04-28.
  25. ^ Naarden, Tirza; ter Meulen, Bastiaan C.; van der Weele, Sarah I.; Blom, Jan Dirk (November 10, 2019). "Alice in Wonderland Syndrome as a Presenting Manifestation of Creutzfeldt-Jakob Disease". Frontiers in Neurology. 10: 473. doi:10.3389/fneur.2019.00473. PMC 6521793. PMID 31143156.
  26. ^ Mastria, Giulio; Mancini, Valentina; Viganò, Alessandro; Piervincenzi, Claudia; Petsas, Nikolaos; Puma, Marta; Giannì, Costanza; Pantano, Patrizia; Di Piero, Vittorio (2023). "Neuroimaging markers of Alice in Wonderland syndrome in patients with migraine with aura". Frontiers in Neurology. 14. doi:10.3389/fneur.2023.1210811/full#:~:text=background:%20the%20alice%20in%20wonderland,associated%20with%20migraine%20in%20adults.. ISSN 1664-2295. {{cite journal}}: Check |doi= value (help)
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