Alice in Wonderland Syndrome - an overview (original) (raw)
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Alice in Wonderland Syndrome: A real life version of Lewis Carroll’s novel
Patrick O'Toole, Edward Justin Modestino, in Brain and Development, 2017
Abstract
Alice in Wonderland Syndrome was originally coined by Dr. John Todd in 1955. The syndrome is named after the sensations experienced by the character Alice in Lewis Carroll’s novel Alice’s Adventures in Wonderland. Alice in Wonderland Syndrome consists of metamorphopsia (seeing something in a distorted fashion), bizarre distortions of their body image, and bizarre perceptual distortions of form, size, movement or color. Additionally, patients with Alice in Wonderland Syndrome can experience auditory hallucinations and changes in their perception of time. Currently, there is no known specific cause of Alice in Wonderland Syndrome. However, theories point to infections such as the Epstein–Barr virus, medications such as topiramate and associated migraines. Neuroimaging studies have revealed brain regions involved with the manifestation of symptoms. These include the temporo-parietal junction within the temporal lobe and the visual pathway, specifically the occipital lobe. There are no current treatments for Alice in Wonderland Syndrome. Further research is needed to find better treatments for Alice in Wonderland Syndrome and to elucidate the exact cause or causes of Alice in Wonderland Syndrome.
URL:
https://www.sciencedirect.com/science/article/pii/S0387760417300049
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Introduction
Alice in Wonderland syndrome is a term applied to altered bizarre perceptions of the size or shape of a patient's body or other objects.1 It is a disorienting neurological condition that affects human perception of the senses of vision, hearing, touch, sensation, and the phenomenon of time.2,3 The name refers to Lewis Carrol's well-known children's book Alice's Adventures in Wonderland,4 in which the title character experiences alterations of sensation in which she felt that her body had grown too tall or too small, or parts of her body were changing shape, size, or relationship to the rest of her body. The syndrome was first described in 1952 by Lippman, and given its name by Todd in 1955.5,6
Affected individuals can experience alterations in perception, including micropsia (objects appear small), macropsia (objects appear large), teleopsia (objects appear further away than they are), and pelopsia (objects appear closer than they are).7 In addition to these alterations in perception, they can also experience hallucinations or illusions of expansion, reduction, or distortion of their own body image.8 These can include microsomatognosia, in which the individual feels that their own body or body parts are shrinking, or macrosomatognosia, in which one feels that their body or body parts are growing inexplicably taller or larger.9 These alterations in size, shape, and perception are collectively known as metamorphopsias or Lilliputian hallucinations. These illusions and hallucinations resemble the strange phenomena that Alice experienced in Lewis Carroll's Alice's Adventures in Wonderland.4 Complete or partial forms of Alice in Wonderland syndrome can occur in a variety of disorders, including migraine, epilepsy, intoxicants, infectious states, the deliria of fevers, and brain lesions (tumors).
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817
Higher Cortical Visual Disorders
Amalie Chen, Sashank Prasad, in Reference Module in Neuroscience and Biobehavioral Psychology, 2023
Alice in Wonderland Syndrome
Alice in Wonderland Syndrome (AIWS) (Todd, 1955), is the descriptive term used to describe a collection of visual distortion or sensory misperceptions: Patient may think objects around them are smaller or larger, closer or farther away, or they may feel they themselves are smaller/larger. They can also have misperceptions of time and space, feeling like time is slowing down or having out of body experiences, respectively. Localization of AIWS is unknown but it is recognized as a symptom of temporal epilepsy (Mendez, 1992; Devinsky et al., 1989), migraine, and meningitis. Case reports (Brumm et al., 2010; Gencoglu et al., 2005) using EEG, fMRI or SPECT imaging have found AIWS symptoms to be associated with changes in activity in the occipital and/or parietal lobes (i.e. hypoactivity in calcarine sulcus and lingual gyrus, hyperactivity in the superior parietal region, hypoperfusion in the frontoparietal region). This may suggest that AIWS occurs when the disease process impacts the visual processing system.
URL:
https://www.sciencedirect.com/science/article/pii/B978032395702100021X
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Alice in Wonderland Syndrome and the Brain
Nuclear medicine techniques using technetium during episodes of Alice in Wonderland syndrome have demonstrated decreased cerebral perfusion in various regions of the brain: the frontal, parietal, temporal, and occipital lobes, either individually or in combination. It was postulated that any condition that caused a decrease in perfusion in the visual pathways or visual centers of the brain could be responsible for the syndrome. Kuo et al. examined four patients with Alice in Wonderland syndrome using single photon emission computed tomography brain scans. For all four patients, areas of reduced cerebral perfusion in the temporal lobe were observed.31 Hiemer et al. believed that the syndrome was caused by an unspecific cortical dysfunction resulting from several possible causes: decreased cerebral perfusion, epileptic activities, or encephalitis.32,33 Another theory suggests that the body image disorders originate in the parietal lobe. Studies have illustrated that electrical stimulation of the posterior parietal cortex can produce disturbances of body image, including the sensation of body length and size distortion.34 Other authors have postulated that decreased blood flow to the nondominant posterior parietal lobe during a migraine attack may cause metamorphopsias. This may also explain why Alice in Wonderland syndrome can occur in association with brain tumors.35
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Epilepsy
Similar to the electrical depolarization theory in migraines, the intense localized electrical changes that occur in the brain during a seizure can induce the symptoms of Alice in Wonderland syndrome. The syndrome has been documented in association with seizures originating in the frontal, occipital, parietal and temporal lobes. The symptoms of Alice in Wonderland syndrome can occur as part of the aura that can precede seizures or as part of the actual seizure.32,40
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Infections
Various infections that cause encephalopathy have been associated with the Alice in Wonderland syndrome. Reported infections include Epstein-Barr virus (EBV), influenza A, H1N1 influenza, Coxsackie B1 virus, Lyme disease, herpes simplex, enterovirus, and varicella.28,44-47 Indeed, infectious mononucleosis caused by EBV has been the most widely reported infectious etiology associated with Alice in Wonderland syndrome.31,45 In one report, EBV infections caused the syndrome in three of ten children.48
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Caro W. Lippman (1886-1954)
A description of symptoms associated with Alice in Wonderland syndrome was first published in medical literature by Caro W. Lippman in 1952, in which he described two patients who experienced a sensation of becoming short and wide during attacks of migraine headache.5 One patient referred to this sensation as her “Tweedledum or Tweedledee feeling,” referring to the short, barreled-shaped characters depicted in Lewis Carroll's 1871 sequel to Alice's Adventures in Wonderland, entitled Through the Looking Glass and What Alice Found There (Fig 5). Lippmann believed that Lewis Carroll experienced migraine headaches, and was inspired by his migrainous attacks in creating Alice and her magical wonderland.9 He wrote, “Alice trod the path of a wonderland well known to the creator,” in reference to Lewis Carroll.5 Lippman claimed that he discovered that certain patients with migraine experienced unique “hallucinations” related to their body image, distortions of the entire body or certain parts of their body. He recorded the “hallucinations” of seven patients, some of whom felt that their body had split in half and the remaining half had either shrunk or grown excessively large. Some of Lippmann's patients were reluctant to explain their odd feelings as they believed they would be considered “crazy.”3 Lippman's first patient felt she was “about one foot tall” during or before the onset of her headache. This patient confirmed that she was hallucinating when she gazed at her reflection in a mirror and saw that she was her normal height. Lippman's sixth patient stated “I get tired from pulling my head down from the ceiling. My head feels like a balloon.”5
FIGURE 5. Tweedledum and Tweedledee, from Through the Looking Glass and What Alice Found There, 1871.
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817
“My little girl tells me she sees strange things”
Göran Darius Hildebrand, in Taylor and Hoyt's Pediatric Ophthalmology and Strabismus (Fifth Edition), 2017
Distortion (dysmetropsia, metamorphopsia, and “Alice in Wonderland” syndrome)
Dysmetropsia and metamorphopsia are related visual illusions where object shapes appear distorted and straight lines bent. Metamorphopsia is best assessed with an Amsler grid. Even relatively young children will be able to say whether the lines are straight or not and report “funny lines.” Visual distortions are either optical (common), macular (occasional), or cerebral (rare) in origin. Optical causes include high corneal, lenticular, or retinal (staphylomatous) astigmatism, high ametropia, anisometropia, and new glasses. Macular causes include macular edema and choroidal neovascularization (e.g. associated with myopic Fuchs maculopathy, inflammatory ocular disease, and macular dystrophies). Rarely visual distortion is of cerebral origin, as in the “Alice in Wonderland” syndrome. A cerebral cause is likely to be accompanied by other neurologic symptoms and signs.
If the Amsler grid confirms the presence of distortions, the management includes refraction and detailed slit-lamp examination of the anterior and posterior segments. Investigations may include optical coherence tomography or fundus fluorescein angiography with macular disease, corneal topography (if keratoconus is suspected) and neuroimaging (magnetic resonance imaging [MRI]) if a cerebral cause is suspected.
Metamorphopsia, micropsia, macropsia, and the Alice in Wonderland syndrome more commonly accompany childhood than adult migraine. Alice in Wonderland syndrome is frequently associated with migraine, but may also be due to epilepsy, drugs/medication (topiramate), varicella infection, or infectious mononucleosis.
URL:
https://www.sciencedirect.com/science/article/pii/B9780702066160001006
Migraine and other Primary Headaches
Donald W. Lewis MD, in Neurologic Clinics, 2009
Other unusual forms of migraine in childhood
Alice in Wonderland syndrome represents the spectrum of migraine with aura, but the visual aura is quite atypical and may include bizarre visual illusions and spatial distortions preceding an otherwise nondescript headache. Affected patients describe distorted visual perceptions, such as micropsia, macropsia, metamorphopsia, teleopsia, and macro- or microsomatognopsia. The visual symptoms likely represent CSD and oligemia involving the parieto-occipital region heralding the headache.
Confusional migraine has perceptual distortions as a cardinal feature. Affected patients, usually boys, abruptly become agitated, restless, disoriented, and occasionally combative. The confusion phase may last minutes to hours. Later, once consciousness returns to baseline, the patients describe an inability to communicate, frustration, confusion, and loss of orientation to time, and they may not recall a headache phase at all. Confusional migraine often occurs after seemingly innocuous head injury occurring in sports (eg, soccer, football, skating). Clearly, any sudden unexplained alteration of consciousness after head injury warrants investigation for intracranial hemorrhage, drug intoxication, metabolic derangements, or epilepsy.
Clinically, confusional migraine most likely represents an overlap between hemiplegic migraine and BM. Patients who present with unilateral weakness or language disorders should be classified as having hemiplegic migraine, and patients with vertiginous or ataxic patterns should be classified as having BM.
Ophthalmoplegic migraine (OM) has been removed from the migraine spectrum into the group of “cranial neuralgias” as a result of elegant neuroimaging evidence demonstrating an underlying demyelinating-remyelinating mechanism. The key clinical feature is painful ophthalmoparesis. The pain may be a nondescript ocular or retro-ocular discomfort. Ptosis, limited adduction, and vertical displacement (eg, cranial nerve III) are the most common objective findings. The oculomotor symptoms and signs may appear well into the headache phase rather than heralding the headache, contrary to the sequence of typical migraine. The signs may persist for days or even weeks after the headache has resolved. Because OM is no longer viewed as migraine, eventually, the term ophthalmoplegic migraine is likely to evolve to ophthalmoplegic neuralgia or neuralgiform disorder.
The migraine precursors and these unusual forms of migraine with aura are unique to pediatrics and represent a challenging group of disorders characterized by the abrupt onset of focal neurologic signs and symptoms (eg, hemiparesis, altered consciousness nystagmus, ophthalmoparesis) followed by headache. Frequently, these ominous neurologic signs initially point the clinician in the direction of epileptic, cerebrovascular, traumatic, or metabolic disorders, and the migraine diagnosis become apparent only after thorough neurodiagnostic testing. Some of these entities occur in infants and young children, in whom a history is limited. Only after obtaining a careful history and performing a physical examination and appropriate neurodiagnostic studies can these diagnoses be comfortably entertained. All represent diagnoses of exclusion.
URL:
https://www.sciencedirect.com/science/article/pii/S073386190800176X
Alice in Wonderland Syndrome: A Historical and Medical Review
Osman Farooq MD, Edward J. Fine MD, in Pediatric Neurology, 2017
Other Early Literature References
Although it is widely accepted that Lippman gave the first true description of this syndrome in 1952, on reviewing the literature, we found other descriptions of patient's symptoms that appear to resemble Alice in Wonderland syndrome. In 1907, William Gowers reported that patients with seizures experienced feelings of “unreality in what is seen.”16 Objects seemed unreal “as if in a picture.”16 In 1913, Hermann Oppenheim noted that one of his patients who experienced migraine headaches manifested unusual symptoms. He stated: “I have seen a case of genuine hemicrania in which there was during an episode of violent migraine an indescribable feeling of detachment of the trunk or extremity after an hour or even a day of spontaneous dizziness.”17 Veraguth declared that micropsia and macropsia were associated with epileptic aura and partial complex epilepsy, but also psychosis and hysteria.18 Following Leroy's 1909 description of Lilliputian hallucinations, he published a series of accounts in the 1920s, building on his original observations.15,19-22 In these accounts, he elaborated that his syndrome of Lilliputian hallucinations consisted of:
Small people, men or women of minute or slightly variable height; either above or accompanied by small animals or small objects all relatively proportionate in size, with the result that the individual must see a world such as created by Swift in Gulliver. These hallucinations are mobile, coloured, generally multiple. It is a veritable Lilliputian vision. Sometimes it is a theatre of small marionettes, scenes in miniature which appear to the eyes of the surprised patient. All this little world, clothed generally in bright colours, walks, runs, plays and works in relief and perspective; these microscopic visions give an impression of real life.23
Kaethe Kollwitz (1867-1945) was an artist who was known for her sociopolitical impressions of Germany during World Wars I and II. In her diary, Kollwitz described symptoms of Alice in Wonderland syndrome during her childhood. She recounted episodes in which objects appeared to grow larger or smaller as well as perceptual disorders where she felt that she was diminishing in size. It was postulated that this may have been the reason why her artistic subjects are often shaped with large hands and faces. It is also speculated that the distortion present in her visual art may have had less to do with a deliberate emphasis of the artist's feelings and more to do with perceptual experience.24
URL:
https://www.sciencedirect.com/science/article/pii/S0887899417305817