Alice in wonderland syndrome
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Alice in wonderland syndrome is a disorder of visual perception. It was inculcated into medical literature by Lipmann in 1952, where he described it as an impairment of time,sense and body image. Symptoms are similar to those perceived by the character in the book (Alice in wonderland) by Lewis Caroll.
It is a rare neuro-ophthalmological entity with varied causes. No large epidemiological data has been published yet. The possible and common causes are listed below. Migraine is the most common cause followed by Infections principally by Epstein Barr virus. AIWS primarily involves the paediatric population.
- Hypnotic states
- Drug intoxication with lysergic acid diethylamide (LSD) or marijuana,
- Cerebral lesions
- Infectious mononucleosis
- Encephalopathy by coxsackievirus , H1N1 influenza, borrelia burgdorferi, scarlet fever, typhoid fever,
- Toxic encephalopathy
|Nervous system pathologies||Migraine, Temporal lobe epilepsy, trauma associated encephalopathy, brain tumors, intracranial aneurysms, acute disseminated encephalomyelitis|
|Psychiatric pathologies||schizophrenia,depressive syndrome,derealization/depersonalization disorder|
|Infectious diseases||lymes disease, shigellosis,Epstein Barr virus infection, coxsackievirus infection,H1N1 influenza virus, CMV and varicella|
|Psychoactive substances||Marijuana,LSD,cocaine,amantia muscaria|
The TPO-C which connects the temporo-occipital, parieto-occipital, and temporo-parietal junctions is where visual and somatosensory information is integrated to generate the inner and external representation of self. Other complex perception can be perceived by the patient if other areas of the brain are involved, evolving into complex somatosensory disorder.Alice in Wonderland syndrome has been attributed to the migrainous cortical dysfunction of the non-dominant parietal lobe.
Studies have shown that electrical stimualtion of the parietal lobe leads to distortion in the size and length of the image perceived.Decreased perfusion to the non-dominant parietal lobe during an attack leads to perception of symptoms.Usually symptoms of AIWS can precede or accompany a migrane attack.
- Metamorphopsia - visual distortions
- Macropsia - seeing images larger than normal
- Micropsia – seeing images smaller than normal
- Achromatopsia – inability to perceive color
- Teleopsia – seeing farther than normal
- Pelopsia – seeing closer than normal
- Visual hallucinations
- Partial/total body macro/micro-matognosia
- Quick-motion phenomenon
- Dysmorphopsia – lines and countours appearing wavy
- Feeling of derealisation, depersonalization, somatopsychic duality
- Alteration in judgement of time
Micropsia and Telopsia are the most common symptoms.
Proposed classification of symptoms in AIWS
|Types||Obligatory symptoms||Facultative symptoms|
|A||Aschematia:partial or total macrosomatognosia or microsomatognosia; paraschematia||Derealization, depersonalization, somatopsychic
duality, aberration in judgement of time
|B||Macro- and micropsia and/or tele- and pelopsia.When micropsia and telopsia appear at the same time and for the same object:porropsia
Lilliputianism (people appearing smaller)
|C||Type A + type B symptoms|
Diagnostic criteria for migraine associated with AIWS
- One or more episodes of self-experienced body schema illusion or metamorphopsia
- Duration < 30 min
- Accompanied by headache or a history of migraine
- RMI, CSF, and EEG all normal (visual evoked potentials may be abnormal)
Lanska and Lanska proposed that Alice in wonderland syndrome can be divided into Pure Alice in wonderland(Inter-personal) and Alice in wonderland like syndrome(Extra-personal), latter being more common.
In diagnostics, MRI and EEG are usually not that helpful
The condition as such is self-limiting. There is no active intervention protocol as of now. Treating migraines can alleviate AIWS symptoms. Antipsychotics have also been tried.
AIWS has no age predilection,but is most commonly seen in children and adolescents.Prognosis usually depends upon the underlying mechanism and should be treated appropriately. Though being self limiting,long term follow-up is required.
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- Mastria G, Mancini V, Viganò A, Di Piero V. Alice in Wonderland Syndrome: A Clinical and Pathophysiological Review. BioMed Research International. doi:10.1155/2016/8243145
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- Beh SC, Masrour S, Smith SV, Friedman DI. Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine. Neurology: Clinical Practice. 2018;8(5):389-396. doi:10.1212/CPJ.0000000000000518