Alice in Wonderland syndrome

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Alice in Wonderland syndrome (AIWS), also known as Todd’s syndrome or Lilliputian hallucinations, is a neurological disorder that affects visual perception. Affected patients experience different types of dimensional and morphological distortions, including micropsia and macropsia. The disorder may be temporary when associated with migraine headaches, seizures, brain tumors, and psychoactive drug use. It may also present as an initial symptom of Epstein-Barr virus infectious mononucleosis. It has been hypothesized that the syndrome may be caused by abnormal electrical activity leading to altered blood flow in areas of the brain that process visual perception.

The name “Alice in Wonderland syndrome” was first coined by British psychiatrist John Todd in 1955 to denote a particular group of symptoms intimately associated with migraine and epilepsy (Todd, 1955) that involve perceptual distortions, that is, altering sensory information about oneself and the world around one.

The interest arose when Todd noticed that some of his patients, who suffered from migraine or epilepsy, had experienced illusions related to their bodies such as, for example, feeling too tall or too short or having the impression that body parts were changing shape or size. The clinical data were similar to those reported previously by Lippman (1952) concerning two patients who claimed to have experienced the sensation of becoming small or large during a migraine attack. Such perceptions seemed to recall those described in the book Alice’s Adventures in Wonderland, written in 1865 by Charles Lutwidge Dodgson under the pseudonym Lewis Carroll. The story tells about Alice, a little girl who, by jumping in the hole of a white rabbit, enters in a world where she lives fantastic experiences, including increasing and decreasing in size. The hypothesis put forward by some authors (Todd 1955; Lippman, 1952; Fine, 2013) is that the writer, suffering from migraine himself, was inspired by his personal feelings to devise this story.

Over time, interest in the Alice in Wonderland Syndrome has grown considerably. Many studies have been carried out that have tried to define its causes and forms of manifestation. The problem is, in fact, that the symptoms can easily be mistaken for those of some psychotic disorders. Some authors (Lippman, 1952; Todd, 1955) noted that many patients were reticent to explain what they felt because of shame and fear of not being believed and that, very often, the doubt of being crazy arose in them. Naming this syndrome is of great benefit to these people, so that they do not develop erroneous beliefs that risk creating suffering and that they are able to seek help more easily.

Symptoms of Alice in Wonderland syndrome

Montastruc et al., in one of their articles, described the various expressions of the syndrome (Montastruc, Schwarz, Schmitt, & Bui, 2012). For the sake of clarity, the symptoms will be reported here according to the division proposed by Podoll et al. (Podoll, Ebel, Robinson, Nicola, 2002), who differentiate them into two groups: essential symptoms and accessory symptoms.

The former are the most typical aspects of AIWS, emerging most frequently, and refer to altered perceptions of the size or shape of one’s entire body or parts of it. Individuals may, for example, feel taller, shorter, thinner, or fatter than in reality (microsomatognosia and macrosomatognosia). It is also possible for just one limb, hand or foot, even the head to be seen different than it should be (aschematia).

The latter, however, are additional symptoms that usually accompany the more common ones. They include visual illusions, whereby other people or objects are perceived as smaller or larger (micropsia and macropsia), more distant or closer (teliopsia and peliopsia), or changed in position (allesthesia). Illusions in the passage of time (temporal distortions), feelings of levitation and difficulty in recognizing faces (prosopagnosia) are also possible. Subjective feelings of dissociation are not uncommon, e.g. the impression that one is observing oneself from above (depersonalization) or that what is happening is not real (derealization).

The symptoms are usually recognized by patients and, as stated earlier, often experienced as something strange and abnormal (egodystonia). This is an aspect of differentiation from psychotic individuals, who instead experience hallucinations as real and as part of themselves (egosyntonia). Syndrome symptoms also differ from psychotic symptoms in that they are usually temporary and short-lived and have a clearly identifiable neurological origin (Montastruc, Schwarz, Schmitt, & Bui, 2012).

There still does not seem to be much clarity on the origins and diagnostic criteria of Alice in Wonderland Syndrome.

From the available data, it is possible to assume that it is diagnosed when one or more symptoms occur under certain conditions: absence of damage to the visual system, abnormal blood flow to the brain areas deputed to visual perception (verifiable by special tests using neuroimaging techniques), recognition of the symptoms by patients as unreal and of temporary duration.

With regard to the onset, however, many studies have tried to investigate what are the causes that lead to the development of Alice in Wonderland Syndrome. The most popular idea today is that, in most cases, the symptoms are due to abnormal cortical arousal. This means that patients have sensory perceptions, i.e. sensations given by the five senses, correct, and that it is the altered electrical transmission of these signals, which occurs in the brain, that causes the hallucinations, changing the normal blood supply to the areas responsible for the formation of perceptions (Hamed, 2010). It has been shown (Kitchener, 2004) that this change can be due to different clinical pictures.

Anamnesis and differential diagnosis

Therefore, a correct anamnesis and a precise differential diagnosis of the patient is of great importance. These steps would allow, first, to exclude a psychotic disorder and, second, to identify the correct medical problem, current or regressed, that led to the development of symptoms. Following are studies that have identified some health situations implicated in the onset of the syndrome. It should be specified, however, that these disorders do not necessarily also involve perceptual alterations and that they can occur even without causing Alice in Wonderland Syndrome.

First of all, already identified by Lippmann (1952) and Todd (1955) is migraine. Todd (1955) also mentions two patients with migraine associated with epilepsy. According to the authors, symptoms of visual illusions, altered perceptions of one’s body, and feelings of dissociation were frequent in these cases.

Some viral diseases also seem to be associated with Alice in Wonderland Syndrome. Copperman (1977) discusses three patients with the Epstein-Barr virus (a herpesvirus) who had distortions in object perception. Lahat (1999) also found these features in patients with mononucleosis. Recent studies have shown further associations with Coxsackie B1 enterovirus and H1N1 influenza virus (Wang, Liu, Chen, Chan, & Huang, 1996). Losada-Del Pozo et al (Losada-Del Pozo, Cantarin-Extremera, and Garia-Penas, 2011) identified cytomegalovirus and varicella virus as possible causes. Bacterial infections have also been considered, among which the bacterium Borrelia seems to play a role in the syndrome (Binalsheikh, Griesemer, Wang and Alvarez-Altalef, 2012).

It should be noted that, again, the factors listed do not necessarily cause AIWS; it is possible and common to cross infections without developing symptoms of the syndrome. Complications of these diseases can lead to focused inflammation in the brain, thus altering function and blood flow in the affected areas. Any alterations in perception seem to be due to such additional effects, in case the affected areas are those deputed to this function (Kuo, Chiu, Shen, Ho and Wu, 1998).

Causes of Alice in Wonderland syndrome

A number of hypotheses have also been made regarding possible psychiatric causes. Bui et al. (Bui, Chatagner and Schmitt, 2010) describe an association between AIWS and depressive disorders. It would seem possible, in fact, that the symptoms occur during a major depressive episode. Other authors (Todd, 1955; Blom, Looijestijn, & Goekoop, 2011) have investigated similarities with psychotic symptoms, going so far as to hypothesize that both schizophrenia and schizoaffective disorder may accompany the syndrome. As stated previously, the differences between AIWS symptoms and psychotic symptoms are generally their recognition by the patient as not real and their temporary duration (Montastruc, Schwarz, Schmitt, & Bui, 2012). An examination of electrical and blood activity (fMRI, functional magnetic resonance imaging) in the perceptual areas of the brain, which, remember, is abnormal in cases of AIWS (Hamed, 2010), can also be performed. Especially in these cases, a careful analysis of the symptoms is important to place them in the right category. Certain drugs, such as ecstasy or cannabis (Losada-Del Pozo, Cantarin-Extremera and Garia-Penas, 2011), can also induce phenomena such as those manifested in AIWS.

Studies show that at the base of the symptoms may even be the intake of certain drugs. In particular, Jürgens et al. (Jürgens, Stork and May, 2011) show how the syndrome can occur due to the side effects of the anticonvulsant topirimate, used precisely in the treatment of migraine. Among the pharmaceutical products that, at certain dosages, trigger the symptoms of AIWS we also find dextromethorphan, used in the treatment of cough (Losada-Del Pozo, Cantarin-Extremera and Garia-Penas, 2011), and oseltamivir, used against some types of influenza (Jefferson, Jones, Doshi and Del Mar, 2009).

As Montastruc et al. (Montastruc, Schwarz, Schmitt and Bui, 2012) state in their review, the link between migraine and Alice in Wonderland Syndrome AIWS, a link hypothesized in the early days by Todd (1955), is the one most reported in the literature and is the line mainly considered in the framing of the syndrome. The information available to date is supported by data from the use of transcranial electrical stimulation and neuroimaging techniques. Hamed (2010), referring to a case of concomitance between migraine and AIWS, states the involvement of the occipital and parietal lobe. This finding is confirmed by the study of Brumm et al. (Brumm, Walenski, Haist, Robbins, Granet and Love, 2011), who were the first to record the brain activity of a patient with the syndrome during a micropsia attack. Using functional magnetic resonance imaging (fMRI), which allows to describe the activity of cortical areas based on the detection of blood flow, the authors found an abnormal activation of the occipital lobe, in the primary and extrastriate regions of the visual cortical areas, and of the parietal lobe. The results are in agreement with Cau (1999) on the possibility of the occurrence of perceptual alterations, such as those present in AIWS, in case of temporo-occipital and parieto-occipital-temporal lessons, underlining the role of these areas in the formation of perceptions.

Interesting data concern the spontaneous onset of Alice in Wonderland Syndrome symptoms in children aged 2-13 years. It would seem, in fact, that it is not so rare to encounter alterations in perceptions in the infantile period, which usually return after a short time. Grant Liu, a pediatrician at the Children’s Hospital of Philadelphia, conducted a study to investigate the expression of symptoms of the syndrome in 48 children with this diagnosis. The most frequent illusions involved seeing objects smaller (micropsia) or farther away (teliopsia). The curious fact, however, is that in 52% of the cases no triggers were identified and, in most subjects, the symptoms regressed spontaneously. Referring back to what was previously mentioned, it is difficult for families to deal with a similar situation, due to the lack of knowledge and the shame and fear arising from not knowing what is happening. Liu himself, in an interview, said that he put so much interest in defining the syndrome to give a voice to children, a voice to parents, to make them able to understand what is happening to their children.

In summary, you can define Alice in Wonderland Syndrome as a constellation of symptoms that lead to perceptual distortions. The most common alterations concern the body or part of it, which are often accompanied by visual illusions, temporal illusions and psychological feelings of dissociation. The syndrome is usually caused by other disorders, such as migraine, epilepsy, viral and bacterial infections, intoxication by drugs or medications or concurrent with psychiatric disorders. A separate issue concerns children, who seem to be able to manifest symptoms spontaneously.

To date, there is no specific treatment for Alice in Wonderland Syndrome. The line followed by doctors is the treatment of the factor that triggered it.

Studies of the syndrome have been very helpful in normalizing symptoms. As previously explained, many patients, not being aware of their real condition, experienced the perceptual distortions as something not normal, and this caused in them feelings of confusion, shame and fear, which often led them not to talk about their difficulties and not to ask for help. Giving name and form to this set of bizarre symptoms, allows those who suffer from them to recognize them for what they are and to detach them from real life, just like Alice who, at the end of the book, discovers that her fantastic adventure was nothing but a dream, vivid in her mind but still other than reality.


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