Alice in Wonderland Syndrome: Causes and Management

Introduction

Alice in Wonderland syndrome (AIWS) is an uncommon condition accounting for various hallucinations/illusions where everything appears bigger or smaller than the actual size. People with AIWS describe experiencing alterations in how they see their environment and even certain body parts - either much bigger or much smaller.

Alice in Wonderland syndrome (AIWS) was first described in 1955 as a perceptual disorder characterized by the contortion of visual perception, body image, and time experience. In the famous Lewis Carroll children's book Alice's Adventures in Wonderland, Alice experiences her body growing larger and smaller. AIWS has started to receive scientific attention. The renewed interest was in exploring the brain's networks mediating symptoms with functional imaging techniques.

What Is Alice in Wonderland Syndrome?

Also known as Todd’s Syndrome, it is a sporadic neuro-ophthalmological perceptual condition, a clinically presentable disorder characterized by short-lived events of metamorphism (distortion of visual perception), body schema, time distortion, derealization, depersonalization, and severe disorientation.

What Are the Causes Of Alice in Wonderland Syndrome?

The syndrome's cause is unclear, but experts believe an association with infection is the primary cause in children, while in adults, head trauma and migraine. In addition, abnormal electrical activity in the brain is believed to cause aberrant blood flow to parts of the brain that process the environment as distinctive visual perception.

Some possible causes are

Central Nervous System Pathologies:

1. Migraine (most common cause).

2. Temporal Lobe Epilepsy: Seizure, a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness.

3. Trauma: Associated encephalopathy (damage or disease affecting the brain) or toxic encephalopathy

4. Tumors (cerebral lesions), aneurysms (ballooning and weakened area in an artery), etc.

5. Acute Disseminated Encephalomyelitis: Widespread inflammatory onslaught that harms myelin, the protective covering of nerve fibers, in the brain and spinal cord.

Infection Diseases:

1. Epstein Barr virus cause (2nd common cause) Infectious mononucleosis (infectious disease).

2. Encephalopathy by coxsackievirus, H1N1 influenza, borrelia burgdorferi, scarlet fever, typhoid fever.

3. Lyme disease, shigellosis, etc.

4. Cytomegalovirus and varicella-zoster virus.

Drug Intoxication:

Montelukast, Dextromethorphan, Topiramate, Risperidone, and Psychoactive substances Marijuana, LSD (Lysergic Acid Diethylamide), Cocaine, Amantia Muscarim.

Psychiatric Disorders:

• Schizophrenia: A condition that impairs a person's capacity for clear thought, feeling, and behavior.

• Depression: This is a mood condition that results in a protracted feeling of melancholy and disinterest. Major depressive disorder is another name for it.

• Derealization/Depersonalization Disorder: Occurs when one persistently or repeatedly feels that someone is observing one from outside your body, or one has a sense that things around are not real.

How Does Alice in Wonderland Syndrome Present Itself?

It depends on patient to patient. Typical episodes are fleet that lasts for a few minutes to half an hour and are not the cause of eye problems but the brain's alternation towards perceiving the environment and one’s body. The syndrome influences multiple sense organs -vision, touch, hearing, and loss of sense of time. AIWS symptoms are

• Migraine: People with AIWS are more likely to experience migraines; researchers and doctors conclude that AIWS is an aura, a sensory indication of migraines. AIWS is associated with migrainous cortical dysfunction (brain inability to pay attention, disorientation, an inability to think clearly) of the non-dominant parietal lobe. Research has shown that electrical stimulation of the parietal lobe leads to distortion in the size and length of the image perceived. In addition, decreased perfusion to the non-dominant parietal lobe during an attack leads to the perception of symptoms.

• Size Distortion: Where one believes that their body or surrounding object are growing either small-micropsia or lager-macropsia.

• Perceptual Distortion: Where one feels that objects nearby are growing larger and closer to themselves- pelopsia, while in telopsia, the object is getting smaller and farther away from themselves than actually.

• Time Distortion: Alice in wonderland syndrome loses the sense of time, where one feels the time is moving faster or too slower than actual time.

• Sound Distortion: Where every sound, even silence, feels loud and intrusive. And in some cases, musical sounds are heard in the drone of traffic.

• Loss of Coordination: Quick-motion phenomenon where muscle movements feel involuntary; one loses all control over a limb and feels uncoordinated or difficult to move.

• Catastrophic Thoughts: Thinking related to ruminating about irrational worst-case outcomes.

• Metamorphopsia: Visual distortions.

• Kinetopsia: All stationary objects start moving.

• Plagiopsia: All vertical lines become slanted.

• Achromatopsia: Inability to perceive color.

• Partial or Total Body Macro or Micro-Matognosia: Imperception of one side of the body.

• Dysmorphopsia: Lines and contours appear wavy.

• Hallucination or Illusion: These are percepts experienced without stimulus or sound. Illusion may have sources from the world or, albeit misperceived, that are often fleetingly.

In some cases, individuals may experience like curtains moving in the wind may be misled for an intruder.

What Are the Diagnostic Criteria for AIWS?

One with AIWS is experiencing such clinical symptoms. It is necessary to take a step forward and book an appointment with mental health care personnel. The expertise will guide and help rule out the cause. Diagnostic criteria for migraine associated with AIWS are as follows:

• More than one episode of self-experienced body schema illusion or metamorphopsia.

• The duration of the episode can be less than 30 minutes.

• History of migraine or accompanied by headache.

• Magnetic resonance imaging (MRI) produces highly magnified detailed images of internal organs like the brain.

• Cerebrospinal fluid analysis to rule out pathological cells, protein content, and infective state.

• EEG is a tool used to track the electrical activity of brain cells.

What Is the Treatment Option for AIWS?

There is no standardized guided treatment plan for AIWS but managed by prescribing medication for symptomatic relief. Rule out the cause and treat accordingly help to reduce or relieve the symptoms and prevent conditions from worsening. Likewise, oncologists advise proper treatment plans for brain tumors, such as surgery, radiation, and chemotherapy, and Infection and stress are managed by medications. Treatment of the migraine can alleviate AIWS symptoms. Antipsychotics have also shown promising results.

Is There Any Complication Related to AIWS?

Alice in Wonderland syndrome (AIWS) does not cause complications but often improves with a proper treatment plan. It is not a sign of a severe problem; neither is it harmful but distributive and considered a self-limiting condition. The prognosis depends on the underlying cause and mechanism and should be treated appropriately.

Conclusion

Alice in Wonderland syndrome is the collaboration of symptoms without a specific cause. It is concluded as a harmless, self-limiting entity and a part of extensive differential diagnosis. More research is required to explain the cause and pathophysiology.