Alice in Wonderland syndrome

Alice in Wonderland syndrome (AIWS), also known as Todd's syndrome or dysmetropsia, is a neuropsychological condition that causes a distortion of perception. People may experience distortions in visual perception of objects such as appearing smaller (micropsia) or larger (macropsia), or appearing to be closer (pelopsia) or farther (teleopsia) away than they actually are. Distortion may occur for other senses besides vision as well.

Alice in Wonderland syndrome
Other namesTodd's syndrome,[1] 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
SpecialtyPsychiatry, neurology
SymptomsMicropsia (disoriented perception on objects)
ComplicationsImpaired vision
Usual onsetBefore, during, or after a migraine[2]
DurationEach symptom is separate and will only occur for a 20-to-50-minute period of time.[3]

Alice in Wonderland Syndrome (AIWS) is often associated with migraines, brain tumors, or psychoactive drug use. It can also be the initial symptom of the Epstein–Barr virus (see Epstein-Barr virus-associated lymphoproliferative diseases).[4] AiWS can be caused by abnormal amounts of electrical activity resulting in abnormal blood flow in the parts of the brain that process visual perception and texture.[5]

Anecdotal reports suggest that the symptoms of mononucleosis commonly occur as AIWS in childhood.[6]

Signs and symptoms

AIWS affects the sense of vision, sensation, touch, and hearing, as well as the perception of one's own body image.[7] Migraines, nausea, dizziness, and agitation are also commonly associated symptoms with Alice in Wonderland Syndrome.[8] Less frequent symptoms also include loss of limb control and dis-coordination, memory loss, lingering touch and sound sensations, and emotional instability.[9]

Visual distortions

Individuals with AIWS can experience hallucinations or illusions of expansion, reduction or distortion of their own 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 metamorphosias, or Lilliputian hallucinations,[9] which refers to objects appearing either smaller or larger than reality.[10] People with certain neurological diseases have also experienced similar visual hallucinations.[11]

Within the category of Lilliputian hallucinations, patients 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.[12] Macropsia is a condition where the individual sees everything larger than it actually is.[13]

One 17-year-old boy described his odd symptoms by the following: "Quite suddenly objects appear small and distant or large and close. I feel as [if] I am getting shorter and smaller 'shrinking' and also the size of persons are not longer than my index finger (a lilliputian proportion). Sometimes I see the blind in the window or the television getting up and down, or my leg or arm is swinging. I may hear the voices of people quite loud and close or faint and far. Occasionally, I experience attacks of migrainous headache associated with eye redness, flashes of lights and a feeling of giddiness. I am always conscious to the intangible changes in myself and my environment".[14]

Although a person's vision of real versus hallucinatory objects is not affected, they will often 'see' objects as the incorrect size, shape or perspective angle. Therefore, people, cars, buildings, houses, animals, trees, environments, etc., look smaller or larger than they should be. Further, depth perception can be altered whereby perceived distances are incorrect. For example, a corridor may appear to be very long, or the ground may appear too close.[9][15]

Hallucinations

Zoopsia is an additional hallucination that is sometimes associated with Alice in Wonderland syndrome. Zoopsias involve hallucinations of either swarms of small animals (e.g. ants and mice etc.), or isolated groups of larger animals (e.g. dogs and elephants etc.).[16] This experience of Zoopsias is shared symptom of a variety of conditions, such as delirium tremens.[17]

In addition, some people may, in conjunction with a high fever, experience more intense and overt hallucinations, seeing things that are not there and misinterpreting events and situations.[18]

Hearing and time distortions

Sufferers of Alice in Wonderland syndrome can also often experience paranoia as a result of disturbances in sound perception. These disturbances can include amplification of soft sounds or misinterpretation of common sounds.[19][20]

A person affected by Alice in Wonderland syndrome may also lose a sense of time, a problem similar to the lack of spatial perspective brought on by visual distortion. Time may seem to pass very slowly, akin to an LSD experience, and the lack of time and space perspective can also lead to a distorted sense of velocity. For example, one could be inching along ever so slowly in reality, yet to an affected person, it would seem as if one were sprinting uncontrollably along a moving walkway, leading to severe, overwhelming disorientation.

Causes

Complete and partial forms of the Alice in Wonderland syndrome exist in a range of other disorders, including epilepsy, intoxicants, infectious states, fevers, and brain lesions.[9] Furthermore, the syndrome is commonly associated with migraines, as well as the use of psychoactive drugs. It can also be the initial symptom of the Epstein–Barr virus (see mononucleosis), and a relationship between the syndrome and mononucleosis has been suggested.[21][6][22][8] Within this suggested relationship, Epstein–Barr virus appears to be the most common cause in children, while for adults it is more commonly associated with migraines.[23]

Cerebral hypotheses

AiWS can be caused by abnormal amounts of electrical activity resulting in abnormal blood flow in the parts of the brain that process visual perception and texture.[5] Nuclear medical techniques using technetium, performed on patients during episodes of Alice in Wonderland syndrome, have demonstrated that AiWS is associated with reduced cerebral perfusion in various cortical regions (frontal, parietal, temporal and occipital), both in combination and in isolation. One hypothesis is that any condition resulting in a decrease in perfusion of the visual pathways or visual control centers of the brain may be responsible for the syndrome. For example, one study used single photon emission computed tomography to demonstrate reduced cerebral perfusion in the temporal lobe in patients with AiWS.[24]

Other theories suggest the syndrome is a result of unspecific cortical dysfunction (e.g. from encephalitis, epilepsy, decreased cerebral perfusion), or reduced blood flow to other areas of the brain.[9][8] Other theories suggest that distorted body image perceptions stem from within the parietal lobe. This has been demonstrated by the production of body image disturbances through electrical stimulation of the posterior parietal cortex. Other researchers suggest that metamorphopsias, or visual distortions, may be a result of reduced perfusion of the non-dominant posterior parietal lobe during migraine episodes.[9]

Throughout all the neuroimaging studies, several cortical regions (including the temporoparietal junction within the parietal lobe, and the visual pathway, specifically the occipital lobe) are associated with the development of Alice in Wonderland syndrome symptoms.[1]

Migraines

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 ischaemia (an inadequate blood supply to an organ or part of the body) 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.[9]

Genetic and environmental influence

While there currently is no identified genetic locus/loci associated with Alice in Wonderland syndrome, observations suggest that a genetic component does exist. One case study showcased a grandmother, mother, son, and daughter all with Alice in Wonderland syndrome,[25] suggesting that AiWS is passed on from parent to child. In addition, there is an established hereditary trait of migraines. Examples of environmental influences on the incidence of AiWS include the use of the drug topiramate and potentially the dietary intake of tyramine. Further research is required to establish the genetic and environmental influences on Alice in Wonderland syndrome.[26]

Diagnosis

Alice in Wonderland syndrome is a disturbance of perception rather than a specific physiological condition. The diagnosis can be presumed when other causes have been ruled out. Additionally, AIWS can be presumed if the patient presents symptoms along with migraines and complains of onset during the day (although it can also occur at night). However, as there are no established diagnostic criteria for Alice in Wonderland syndrome, there is likely to be a large degree of variability in the diagnostic process and thus it can be poorly diagnosed.[23]

Prognosis

Whatever the cause, the bodily related distortions can recur several times a day and may take some time to abate. As a consequence, the person can become alarmed, frightened, and panic-stricken throughout the course of the hallucinations, and affected people may even hurt themselves or others around them as a result of this alarm. The symptoms of the syndrome themselves are not inherently harmful and are likely to disappear with time, as most patients outgrow these episodes. The long-term prognosis typically depends on the root cause of the syndrome, which must be evaluated and treated.

Often, difficulty lies within the patient's reluctance to describe their symptoms out of fear of being labeled with a psychiatric disorder. Nonetheless, it is usually easy to rule out psychosis as those with Alice in Wonderland syndrome are typically aware that their hallucinations and distorted perceptions are not 'real'.[27] Younger patients may struggle to describe their unusual symptoms, and thus, one recommended approach is to encourage children to draw their visual illusions during episodes.[28]

Symptoms of AiWS do not appear to change in severity over the course of the syndrome, and though the symptoms may acutely impact the patient's life while they are present, Alice in Wonderland syndrome typically resolves itself within weeks or months.[29] Furthermore, AiWS symptoms tend to for short periods of time during the day, with most patients describing their symptoms as lasting anywhere between 10 seconds to 10 minutes.

Treatment

At present, Alice in Wonderland syndrome has no standardized treatment plan. Rather, treatment methods revolve around migraine prophylaxis, as well as the promotion of a low tyramine diet. Drugs that may be used to prevent migraines include anticonvulsants, antidepressants, calcium channel blockers, and beta blockers. Other treatments that have been explored include repetitive transcranial magnetic stimulation (rTMS). Further research is required to establish an effective treatment regime.[8] Visual distortion symptoms can also be relieved by getting close to and looking at the objects in question, and by slowly proceeding to look at things further away.

Epidemiology

The lack of established diagnostic criteria or large-scale epidemiological studies on Alice in Wonderland syndrome means that the exact prevalence of the syndrome is currently unknown. One study on 3,224 adolescents in Japan demonstrated the occurrence of macropsia and micropsia to be 6.5% in boys and 7.3% in girls, suggesting that the symptoms of AiWS may not be particularly rare.[30] This also seems to suggest a difference in the male/female ratio of AiWS patients. However, according to other studies, it appears that the male/female ratio is dependent on the age range being observed. Studies showed that younger males (age range of 5 to 14 years) were 2.69 times more likely to experience AiWS than girls of the same age, while there were no significant differences between students of 13 to 15 years of age. Conversely, female students (16- to 18-year-olds) showed a significantly greater prevalence.[23]

The average age of the start of Alice in Wonderland syndrome is six years old, but it is very normal for some patients to experience the syndrome from childhood up to their late 20s.[8] Because many parents who have AiWS report their children having it as well, the condition is thought possibly to be hereditary.[31]

History

The syndrome is sometimes called Todd's syndrome, in reference to an influential description of the condition in 1955 by Dr. John Todd (1914–1987), a British consultant psychiatrist at High Royds Hospital at Menston in West Yorkshire.[32][15][33] Dr. Todd discovered that several of his patients experienced severe headaches causing them to see and perceive objects as greatly out of proportion. In addition, they had altered sense of time and touch, as well as distorted perceptions of their own body. Despite having migraine headaches, none of these patients had brain tumors, damaged eyesight, or mental illness that could have accounted for these and similar symptoms. They were also all able to think lucidly and could distinguish hallucinations from reality, however, their perceptions were distorted.[34]

Since Lewis Carroll had been a well-known migraine sufferer with similar symptoms, Dr. Todd speculated that Carroll had used his own migraine experiences as a source of inspiration for his famous 1865 novel Alice's Adventures in Wonderland. Carroll's diary reveals that in 1856 he consulted William Bowman, an eminent ophthalmologist, about the visual manifestations of the migraines he regularly experienced.[35]

Society and culture

Gulliver's Travels

Alice in Wonderland syndrome's symptom of micropsia has also been related to Jonathan Swift's novel Gulliver's Travels. It has been referred to as "Lilliput sight" and "Lilliputian hallucination", a term coined by British physician Raoul Leroy in 1909,[36] based on the small people that inhabited the island of Lilliput in the novel.[37]

Alice in Wonderland

Alice in Wonderland syndrome was named after Lewis Carroll's famous 19th-century novel Alice's Adventures in Wonderland. In the story, Alice, the titular character, experiences numerous situations similar to those of micropsia and macropsia. The thorough descriptions of metamorphosis clearly described in the novel were the first of their kind to depict the bodily distortions associated with the condition. There is some speculation that Carroll may have written the story using his own direct experience with episodes of micropsia resulting from the numerous migraines he was known to suffer from.[38] It has also been suggested that Carroll may have suffered from temporal lobe epilepsy.[39]

House

The condition is diagnosed in the season 8 episode Risky Business.

Doctors

In April 2020, a case of Alice in Wonderland syndrome was covered in an episode of the BBC daytime soap opera Doctors, when patient Hazel Gilmore (Alex Jarrett) experienced it.[40]

See also

References
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