Alice in Wonderland Syndrome: Look into the rabbit hole

Most are familiar with the popular novel and movie Alice in Wonderland. As Alice turns down the rabbit hole, the world as she knows it appears irrevocably different. It’s made so much of an impact that scientists have named a medical condition after the story. Alice in Wonderland Syndrome, also known as Todd Syndrome, is a neuropsychiatric condition causing distortions in the senses—specifically in visual perception. These perceptual changes have a variety of causes and are associated with key signs and symptoms.

Alice in Wonderland Syndrome
Photo by Vinicius “amnx” Amano on Unsplash

What is Alice in Wonderland Syndrome 

First called Todd Syndrome by the British psychiatrist John Todd in 1955, Alice in Wonderland Syndrome was given its name because of its symptoms which alter the perception of body image. The syndrome resembled the shifts in the way Alice perceives the world as she falls down the rabbit hole with her body rapidly shifting from big to small.

People with it see themselves and objects as larger or smaller, farther or closer, than they actually are. It affects vision, hearing, touch or sensation, and body image. The altered perception of the senses occurs in episodes and may be referred to as hallucinations and cognitive distortion. Studies of 81 cases of Alice in Wonderland Syndrome found that episodes range from less than 5-minutes to 2-days.

Symptoms of Alice in Wonderland Syndrome

Symptoms of it involve distortions in the perception of the senses. This most commonly affects visual input of the body, faces, objects, and colors. For example, three-dimensional objects may appear flat, change colors, or look as if they are tilted. Any of the below symptoms can manifest in it:  

  • Micropsia—objects appearing smaller
  • Macropsia—objects appearing larger
  • Pelopsia—objects appearing closer
  • Teleopsia—objects appearing farther away
  • Microsomatognosia—feeling of body parts shrinking
  • Macrosomatognosia—feeling of body parts becoming larger
  • Hallucinations—illusions of expansion, often including seeing animals that are not there
  • Hearing distortions—soft sounds are amplified and become louder
  • Time distortions—slowing or quickening of reality  
  • Dizziness—sensation of spinning caused by the perception of objects or people moving
  • Nausea—gastrointestinal upset from dizziness
  • Mood disturbanceagitation and emotional instability have been reported
  • Memory loss—in rare cases, cognitive decline leads to memory loss

Causes of Alice in Wonderland Syndrome 

Episodes of it are typically brief, which makes it difficult for physicians to identify the underlying cause. However, the rare condition is more likely to develop in children than in adults. Many outgrow the condition after childhood.

Symptoms of it occur to some extent in multiple other conditions such as brain tumors and lesions, epilepsy, infections, and head trauma. The Epstein-barr virus is a frequent trigger too, which helps account for its prevalence in children and teens. Those with acute disseminated encephalomyelitis—inflammation of the brain and spinal cord that damages the brain’s protective nerve fibers—are also prone to Alice in Wonderland Syndrome.

Migraines and Alice in Wonderland Syndrome 

Both as a symptom and a potential cause, it is strongly associated with migraine headaches. The connection remains under speculation, but experts hypothesize that the rare syndrome occurs as an aura preceding a migraine. An aura includes flashing lights in vision, numbness, or tingling in addition to altered perception. This form of migraine does not always include head pain. According to current research, a child with it has a 50% increased chance of developing migraine headaches if they have family members with migraines.

Brain Changes Associated with Alice in Wonderland Syndrome 

Abnormal electrical activity in the brain is associated with Alice in Wonderland Syndrome because it interferes with the blood flow in the areas of the brain responsible for visual perception. This is founded through brain imaging with evidence of damage. Subjects with brain lesions in the parietal and temporal lobes were observed to suffer from Alice in Wonderland Syndrome more frequently than those with lesions in other areas.

Alice in Wonderland Syndrome
Photo by Robina Weermeijer on Unsplash

Diagnosing Alice in Wonderland Syndrome 

There are no criteria for diagnosing Alice in Wonderland Syndrome. The diagnosis relies on the process of elimination to rule out other causes for a patient’s symptoms, as well as looking for the disorders that are thought to lead to Alice in Wonderland Syndrome. After collecting a thorough medical and family history, physicians tend to order blood tests to determine whether the Epstein-Barr virus or another infection is present. A brain scan known as Magnetic resonance imaging (MRI) can locate lesions and brain tumors that can be attributed to the episodes of perceptual distortions.

Those experiencing episodes of Alice in Wonderland Syndrome may prove hesitant to express their symptoms to a medical professional out of fear of being labeled as having a psychiatric disorder. Neurologists, doctors that treat disorders of the nervous system, or psychiatrists who treat mental illness, are typically the first to inquire about the symptoms of Alice in Wonderland Syndrome. It’s crucial to differentiate the misperceptions with hallucinations related to mental illnesses like schizophrenia.

Treating Alice in Wonderland Syndrome 

Alice in Wonderland Syndrome has no established treatment. Management of the condition, aside from waiting until the episodes pass, is directed toward treating the suspected cause. For example, if an infection has triggered Alice in Wonderland Syndrome, treating the infection with a course of antibiotics can relieve symptoms. Alice in Wonderland Syndrome connected to migraine headache requires migraine treatment to prevent its reoccurrence.

Medications

Medications prescribed for Alice in Wonderland Syndrome treatment are mainly those used for migraine prophylaxis. The most successful pharmaceutical combination includes antidepressants, anticonvulsants, beta-blockers, and calcium channel blockers. The latter drugs reduce the blood flow and limit the vasodilation of the vessels that are linked to migraines.

Antidepressants and anticonvulsants are also effective for cases secondary to depression and epilepsy. Antiviral and antibiotics treat Alice in Wonderland Syndrome when induced by viral or infectious illness.

Diet

Dietary changes for migraine prevention are effective for many with Alice in Wonderland Syndrome. Following a low tyramine diet is recommended. Tyramine, a compound produced from the amino acid tyrosine, is found naturally in the body and food. Foods with a high tyramine content trigger migraines. They include foods that have been fermented or aged: cheese, alcoholic beverages, vinegar, cured meats, soy products, dried fruits, pickles, sauerkraut, and yeast. Limiting high tyramine foods prevents migraines, which then prevents episodes of Alice in Wonderland Syndrome. Incorporating plenty of fresh fruits and vegetables, as well as consume small, frequent meals to ward off hunger headaches are simple changes to make to benefit symptoms.

Therapy

Stress exacerbates the symptoms of Alice in Wonderland Syndrome. Practicing deep breathing and meditation keep stress levels down, which is a helpful asset in conjunction with medication and lifestyle changes.

Distortions visual and other sensory perceptions are frightening to the person experiencing them. Because of this, cognitive behavior therapy is a way to express those emotions. One study of a 13-year-old female with Alice in Wonderland Syndrome had fewer episodes by undergoing relaxation training and cognitive behavior therapy aimed at trading negative patterns of behavior for productive ones.

Prognosis of Alice in Wonderland Syndrome 

The prognosis of Alice in Wonderland Syndrome depends on the underlying cause. The majority of cases are benign, only occurring briefly on one or two occasions until symptoms abate on their own like in the instance of the Epstein-Barr virus and infection. Alice in Wonderland Syndrome secondary to chronic conditions (i.e. epilepsy, migraines) recurs and does not resolve without treating the cause. Children with Alice in Wonderland Syndrome have a greater chance of disease remission.