Patients with Alice in Wonderland syndrome (AIWS) see the surrounding world far differently from those around them. Sensory distortions cause AIWS patients to see objects smaller or larger than they actually are—including parts of their own body.

Little is known about AIWS, and although more common than previously thought—especially among persons with migraine—the condition is still rare, according to authors writing in Psychiatry International.

Hernandez J. The perplexing mental health comorbidity of Alice in Wonderland syndrome (AIWS): a case study. Psychiatry Int. 2023;4(1):30–34.

 

 

Presentation

 

AIWS results in transitory events of distorted perception and disorientation (ie, metamorphopsias). Some of the distortions that patients experience include brief sensations of feeling smaller or larger than they really are, or perceiving the room in which they are located as appearing much larger or smaller than it actually is. The furniture may look distorted, as well. Importantly, this condition affects all senses and perceptions, including vision, touch, and hearing.

To the early researchers who identified the syndrome, “Patients with this syndrome described their physical frame as being altered in illusions with changes in forms, dimensions, and motions of objects,” note the authors in Psychiatry International.

 

Diagnosis

 

AIWS is a diagnosis of exclusion and made using presenting signs and symptoms. No ICD-10 or DSM-5 criteria have been confirmed for the condition.

Overall, EBV infection is the most common cause of AIWS in children, whereas migraine is the most common cause in adults.

Investigations into the pathophysiological mechanisms underlying AIWS are limited. In cases where CNS lesions are the underlying etiology of AIWS, recent research has found that such lesions most commonly affect the extrastriate visual cortex. In cases of non-structural causes of AIWS, however, the role of a similar brain network has not been confirmed.

Mastria G, Mancini V, Viganò A, et al. Neuroimaging markers of Alice in Wonderland syndrome in patients with migraine with aura. Front Neurol. 2023;14:1210811.

 

In one study, investigators used lesion network mapping to test whether the location of lesions that cause AIWS fall within a common brain network, which was defined by connectivity to a specific set of distant regions.

Friedrich MU, Baughan EC, Kletenik I, et al. Lesions causing Alice in Wonderland Syndrome map to a common brain network linking body and size perception. Published online January 18, 2024. doi:10.1101/2024.01.17.24301332.

 

“Taken together,” the investigators wrote, “we hypothesize that lesions causing AIWS, due to their specific connectivity profile, simultaneously disrupt two higher-order brain functions related to body perception and judgement of size and scale.” 

 

Personalized treatment

 

Management of AIWS should be personalized, as there is no definitive medication regimen for the condition. The need for treatment is based on the natural course of underlying conditions. Specialists may consider prescribing migraine preventive medications, antibiotics, antivirals, or anti-epileptics, based on the cause. Most clinical cases of AIWS are benign and resolve spontaneously, or do so after treatment.

Individuals who have migraine or epilepsy, and also those with encephalitis, may experience a recurrence of AIWS symptoms when the disease is active.

Blom JD. Alice in Wonderland syndrome: a systematic review. Neurol Clin Pract. 2016;6(3):259–270.

 

 

An exception to pharmacotherapy for AIWS is antipsychotic medications, which are not considered useful. When distortions occur as a comorbid symptom in a patient with psychosis, it is important to know that these distortions can sometimes be triggered or exacerbated by antipsychotic medications.These medications can lower the threshold for epileptic activity.