Alice in Wonderland syndrome (AIWS) is a rare neurological condition where people experience an inaccurate perception of their body and/or the objects surrounding them. John Todd was the first to use the term AIWS; thus, it is also known as Todd’s syndrome. This syndrome can occur at any age but is commonly found in children, with the mean age of onset at 8.5 years.
This syndrome gets its name from the famous character ‘Alice’ from the book ‘Alice’s Adventures in Wonderland’ by Lewis Carroll. In the book, Alice experiences many strange feelings, such as a loss of sense of time, body size becoming too small or large and a lack of perception of time and space, such as the body appearing to move faster than the distance covered. Such uncanny descriptions in the book suggest that Lewis Carroll wrote about it from his experiences during his migraine episodes.
According to neurologists, a standard classification of AIWS is lacking, causing diagnostic difficulties. One study proposed to consider the perception of one’s body size increasing or decreasing in size (somesthetic) as the core of AIWS, and other symptoms, including visual illusions, such as objects or other people appearing larger or smaller in size and complex psychic symptoms, should be considered as facultative and are independently insufficient to diagnose AIWS.1
Another study divided patients into subgroups based on the symptoms observed in them.1
Type A: Patients with somesthetic symptoms with disturbances in self-perception of body size
Type B: Patients with visual illusions (most prevalent type) with patients experiencing distortions in visual processing in people or things around them
Type C: Patients having symptoms of types A and B (both self-perception and visual processing are affected)
The most frequent causes of AIWS in descending order are as follows:1
The symptoms are classified as somesthetic and visual illusions.1
These symptoms affect the way a person perceives his surroundings.
The distortions can make the patient anxious, terrified and panic-stricken, and these inaccurate perceptions may occur several times during the day and take from a few minutes to a few hours to subside.
A lack of standard and widely accepted diagnostic criteria and the absence of large-scale epidemiological studies prevent the exact prevalence of the syndrome from being known. A study conducted on adolescents (between 13 and 18 years) showed that visual illusions were found in 7.3% of girls and 6.5% of boys.
The prevalence of the disorder in males and females differs with age. In a study conducted in patients between the ages of 5 and 14 years, males were at a 2.69-fold risk of being affected with AIWS than females. In children between the ages of 13 and 15 years, no difference in prevalence was noted, whereas 56.7% of females suffered from the disorder between the ages of 16 and 18 years.
The temporoparietal-occipital carrefour (TPO-C, a region in the cerebral cortex [outermost layer of the brain and has many folds on its surface] where the temporal [located behind the ears], parietal [located upper rear part of the head] and occipital lobes [back of the head] meet) is the primary location of the brain where AIWS symptoms develop. This region encompasses the somatosensory and visual information that provides the internal-external representation of self. When the ability of the brain to process sensory input is disrupted, it affects the perception of one’s body size and the objects around us.
A study conducted a functional magnetic resonance imaging (MRI) to evaluate the brain function of a 12-year-old boy during an episode of micropsia. It showed increased activation of the parietal regions compared with the control who demonstrated activation of the visual areas of the occipital lobe during a passive (reverse checkerboard, comprising a black and white checkerboard in which the squares flip between black and white at short intervals (milliseconds) and an active (Ponzo illusion, a common optical illusion that impacts size judgment) visual processing task. This suggests that the visual regions in the occipital lobe do not respond accurately during an episode of micropsia.
As there are no standard diagnostic criteria, a detailed medical history and thorough physical examination, including neurologic, ophthalmic, and otologic evaluations, should be conducted. The clinician should be well-versed with the symptoms and causes as they can be confused with the symptoms of other perception disorders, such as hallucinations and illusions.
Brain computed tomography (CT) and MRI used by neurologists for the analysis of structural changes in the brain are usually normal in AIWS. Electroencephalograms (EEGs) used to analyse the electrical activity of the brain may be abnormal in patients with epilepsy. Single-photon emission CT has revealed hypoperfusion (reduced blow flow) of the temporal lobe and surrounding the optic tract and its connections.
For migraine-associated AIWS, the diagnostic criteria are as follows:
Most non-clinical and clinical AIWS cases are benign, and the symptoms resolve spontaneously or following appropriate treatment. In clinical cases associated with an underlying condition, such as epilepsy, migraine or infection, symptoms may recur during the active phase of the disease. In such cases, the treatment is aimed at addressing the underlying condition, including migraine prophylaxes, anti-epileptics, antibiotics or anti-viral agents.
Although the prognosis depends on the cause, it is usually good as episodes decline in severity and frequency as time progresses. AIWS is a benign condition and does not require specific treatment or long-term follow-up; however, underlying medical conditions, such as cerebrovascular accidents, epilepsy, and encephalitis, must be ruled out.
AIWS is a rare condition occurring due to alterations in the brain processes that aid in the perceptions of self and the surroundings. People can experience their body size or the things or people around them appearing smaller or bigger. Objects can appear to be farther away or nearer relative to their position. Diagnosis should be performed by experienced clinicians who can accurately evaluate the underlying causes and symptoms. Addressing the underlying cause and providing the necessary intervention can improve the patient’s quality of life.
At Kauvery Hospital, with branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy, our team of expert neurologists are fully equipped to diagnose and treat rare neurological conditions like Alice in Wonderland Syndrome. Committed to enhancing patient health and wellbeing, we deliver comprehensive and effective healthcare solutions tailored to individual patient needs. Connect with our team today for expert advice and personalised care.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
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