Alice in Wonderland Syndrome

Alice in Wonderland syndrome (AIWS) is a rare neurological condition characterized by disturbances in visual and/or somatosensory perception. It was first described by J. Todd in 1955 and named after the surreal experiences of the character in Lewis Carroll’s Alice’s Adventures in Wonderland. This syndrome can cause temporary or permanent alterations in the perception of object size, shape, spatial relationships, or one’s own body.

^{Representative AIWS image (generated by artificial intelligence)}

The underlying causes of AIWS are complex and have been associated with numerous different conditions. The most commonly linked conditions include:

• Migraine: AIWS is recognized as a frequent symptom, particularly in patients with migraine with aura. It may occur during or before migraine attacks and is thought to be related to neurophysiological events such as cortical spreading depression.
• Epstein-Barr Virus (EBV) Infection: Especially in children, EBV infection is considered one of the most common causes of AIWS. EBV may induce this syndrome through direct or indirect effects on the central nervous system.
• Infections: Other viral infections such as influenza, measles, and chickenpox, as well as bacterial infections, have also been associated with AIWS. These infections may lead to brain inflammation or transient neurological dysfunction.
• Brain Lesions: Structural lesions such as brain tumors, stroke, and traumatic brain injury can cause AIWS symptoms. Lesions in the parietal and temporal lobes are particularly likely to affect visual and somatosensory perception.
• Psychiatric Disorders: Certain psychiatric conditions, especially derealization or depersonalization disorders, may present with symptoms similar to AIWS or co-occur with it. However, AIWS is primarily a perceptual disorder and not a psychotic condition.
• Drug Use: Some medications, such as hallucinogens and certain antidepressants, may produce AIWS-like symptoms as side effects.
• Other Conditions: Seizures, thyroid dysfunction, certain autoimmune diseases, and other rare neurological syndromes have also been associated with AIWS.

The symptoms of AIWS vary widely between individuals and tend to occur episodically. The most common perceptual disturbances include:

• Dysmetropsia: Perceptual distortions in the size of objects or people, ranging from micropsia (objects appearing smaller than they are) to macropsia (objects appearing larger than they are).
• Teleopsia/Poroopsia: Misperception of distance. Teleopsia is when objects appear farther away; poroopsia is when they appear closer.
• Pelopsia: Objects may appear both closer and larger than they actually are.
• Dismorphopsia: Distorted perception of object shapes or contours.
• Aschematia (Body Schema Disturbances): Altered perception of one’s own body size or shape, manifesting as sensations of body parts shrinking, enlarging, elongating, or shortening.
• Derealization/Depersonalization: The environment may feel unreal or foreign (derealization), or the individual may feel detached from their own self (depersonalization).
• Disturbances in Time Perception: Alterations in the perception of time, such as feeling that time is slowing down or speeding up.
• Auditory and Tactile Perception Disturbances: Less commonly, changes in the intensity of sounds or tactile sensations may occur.

Symptoms are typically brief, lasting minutes to hours. They often emerge in association with triggering factors such as stress, fatigue, or fever. AIWS is reported to occur more frequently in children and young adults.

^{Representative AIWS image (generated by artificial intelligence)}

The diagnosis of AIWS is based on a detailed clinical history and evaluation of perceptual symptoms. There is no specific laboratory test or imaging method to confirm the diagnosis. Before diagnosing AIWS, it is essential to rule out other neurological, psychiatric, or systemic conditions that may cause perceptual disturbances. For this purpose, brain imaging (MRI, CT), electroencephalography (EEG), laboratory tests (infection screening), and neurological examination may be performed.

The pathophysiology of AIWS is not fully understood, but it is associated with dysfunction in various brain regions:

• Parietal Lobe: Involved in spatial perception, visuospatial attention, and body schema. Abnormalities in this region may lead to dysmetropsia and aschematia.
• Temporal Lobe: Associated with visual processing, facial recognition, and emotional processing. Temporal lobe dysfunction may contribute to visual perceptual disturbances.
• Occipital Lobe: Contains the visual cortex. Functional disturbances here can directly cause visual perceptual abnormalities.
• Thalamus: Plays a critical role in relaying sensory information to the cortex. Thalamic dysfunction may result in sensory perception disturbances.
• Cortical Spreading Depression (CSD): In AIWS associated with migraine, CSD is thought to trigger perceptual disturbances by causing transient changes in brain activity.

There is no specific treatment for AIWS. Management typically focuses on addressing the underlying cause. For example, in migraine-associated AIWS, migraine treatment (acute and preventive) may reduce the frequency and severity of symptoms. In infection-related cases, treating the infection is essential. Rarely, anticonvulsants or migraine medications may be used for symptomatic relief.

The prognosis for AIWS is generally favorable. Symptoms are usually transient and tend to resolve spontaneously. In children, symptoms often diminish or disappear entirely with age. However, in some individuals, episodes may persist for years. Excluding serious underlying neurological conditions such as tumors is crucial for prognosis.

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