Article summary of Alice in Wonderland syndrome: A systematic review by Blom - Chapter

What symptoms comprise Alice in Wonderland syndrome? 

Alice in Wonderland syndrome (AIWS) was first described in 1955 by the psychiatrist John Todd, and its symptoms include various distortions of sensory perception, including visual distortions, and distortions of time and self. These distortions differ from hallucinations and illusions in the sense that they are based in the real world but involve very specific alterations to sensory input. AIWS currently comprises 42 visual symptoms (called metamorphopsias) and 16 non-visual symptoms. The two most common symptoms are micropsia; seeing things as smaller than they really are, and macropsia; seeing things as larger than they really are. 58.6% of AIWS patients suffer from micropsia while 45% suffer from macropsia. A few other visual symptoms include kinetopsia, in which people see stationary objects as moving, and prosopometamorphopsia, in which eyes are seen as much larger than they are. Symptoms sometimes include feelings of levitation and alterations in the passage of time, among others. It is most common for people with AIWS to only experience one symptom, although many people experience up to four. Generally, AIWS symptoms tend to be short-lived, lasting a few minutes to a few days. Years-long or lifelong symptoms occur rarely.

What are the causes of AIWS? 

There are many possible causes of AIWS, and more will likely be added as more cases are identified. The causes differ between young people and adults. For youths, the most common cause of AIWS is encephalitis (inflammation of brain tissues). Encephalitis can be caused by various infections, but the Epstein-Barr virus is the one most frequently cited in cases of encephalitis-induced AIWS. In adults, neurological disorders were cited most often as the medical cause for AIWS, with migraines being the most common among them. However, symptoms of AIWS are sometimes unassociated with any type of medical disorder or pathology. Symptoms of this syndrome are caused by functional and/or structural abnormalities in the perceptual system.

What are the prevalences of AIWS in the population? 

Although AIWS is thought of as a rare syndrome, some of its symptoms are seen quite regularly in the general population. In fact, singular symptoms of AIWS unrelated to another disorder or medical condition have been experienced by around 30% of all adolescents. When considering specific symptoms, it was found that 5.6% of male adolescents and 6.2% of female adolescents have experienced micropsia and/or macropsia. It was also found that 15% of patients with migraines suffer from AIWS.

What are the treatment methods and prognoses for AIWS? 

Patients with AIWS often suffer from underlying medical conditions like encephalitis, migraines, or epilepsy. When this is the case, pharmacological treatment is used in an attempt to diminish or eliminate the underlying cause. Typically, medication is only necessary in medically-induced cases, and this treatment must target the medical condition rather than the symptoms themselves. Generally, these treatments include antiepileptic medication, antibiotics, antiviral medication, or migraine medication. Oftentimes in medical cases of AIWS, symptoms disappear and return in coordination with the severity of the disease at the time. In most cases of non-medically-induced AIWS, a helpful treatment can consist merely of reassurance from a clinician that the symptoms they are experiencing are benign. Chronic cases may warrant functional neuroimaging to better understand specific symptoms. Almost all cases of AIWS are considered benign and treatable, as full remission of symptoms is often achieved both in medically-induced and non-medically induced cases. This can occur either spontaneously or after treatment. However, the prognosis for patients with epilepsy or migraine-induced AIWS is poorer — these patients rarely achieve full remission due to the difficulty of treating their underlying conditions.

Why is AIWS so regularly discounted in scientific literature and clinical practice? 

It is estimated that AIWS is severely underdiagnosed. This is partially due to its apparent similarities to schizophrenia spectrum disorders, as patients’ perceptual distortions may be attributed to hallucinations. The diagnosis of AIWS is also made more difficult because it is not featured in either the DSM-5 or the ICD-10. In practice, symptoms of AIWS may not be recognized because of this factor. It is suggested that AIWS should be included in the next versions of the DSM and ICD under the categorization of nervous system disorders or perceptual disorders. An international database that documents cases of AIWS and their treatments would also be extremely helpful for clinicians trying to learn about and diagnose this syndrome.