What is… Alice in Wonderland Syndrome?

Guest post by Hassan Osman

(1) Alice in Wonderland.

Back in 1865, Charles Lutwidge Dodgson’s (under the pseudonym Lewis Carroll) “Alice’s Adventures in Wonderland” was a “hit” that is still taught in basic literature courses today. Since then, the novel was turned into a cartoon and has gained even more fans. The novel “Alice’s Adventures in Wonderland” has been treated by many of us as a children’s bedtime story (or movie) in which we are granted the opportunity to, in a sense, escape reality.

You may have thought that Alice in Wonderland is just fantasy. But what if I told you that Alice is so real that an actual medical syndrome was named after her?  Alice in Wonderland Syndrome (AIWS) is a condition characterized by a vast array of cognitive symptoms. Have you ever experienced abnormal perception of time or perceived things as larger or smaller than they actually are? If so, you may be able to relate to this syndrome.

Personally, I stumbled upon this syndrome accidentally. Being a medical student, I have the tendency to look up medical information online, offline and everywhere in between. One night, while surfing PubMed, I came across Dr. JD Blom’s (2016) paper entitled, “Alice in Wonderland syndrome: A systematic review”. The title caught my eye and sparked my curiosity. Since then, I’ve read much more about the syndrome, wrote a review article, and wrote a book on the topic. The experience of researching the syndrome, much like the syndrome itself, has been quite surreal! In the following paragraphs, I discuss the history of the syndrome, its signs and symptoms, and how to diagnose and treat the condition.

History of AIWS

The first acknowledgement of AIWS as a clinical phenomenon can be attributed to CW Lippmann in 1952 in a paper titled Certain hallucinations peculiar to migraine. J. Todd identified the syndrome and was the first to name it in a 1955 paper entitled, The Syndrome of Alice in Wonderland. In his paper, Dr. Todd discusses a rather peculiar set of signs and symptoms associated with a number of causes as well as multiple case reports on the subject.

Although the syndrome was not identified by name at the time, many believe that Lewis Carroll might have suffered from the syndrome himself, especially considering his reported experimentation with drugs.

Image result for time surreal
(2) Alice in Wonderland Syndrome is associated with abnormal perception of the passage of time.

Clinical signs and symptoms

Dr. Jan Dirk Blom’s (2016) Alice in Wonderland syndrome: A systematic review identifies the clinical signs and symptoms of AIWS, which include, but are not limited to:

1) The perception of objects as being larger than their true size (macropsia)
2) The perception of objects as being smaller than their true size (micropsia)
3) The perception of objects as being nearer in distance than they truly are (pelopsia)
4) The perception of objects as being further away in distance than they truly are (teleopsia)
5) Abnormal perception of time as it passes
6) Zoom vision: an alternation between macropsia and micropsia
7) Distortion of body image
8) Distortion of shapes of objects (meta-morphopsia)

Approximately 30% of adolescents have reported experiencing symptoms of AIWS (maybe you or someone you know).   

Causes of AIWS

AIWS is not a stand-alone syndrome, but occurs as a result of a disease affecting perception or mental function more generally.  For example, AIWS is often associated with migraines, substance use, or brain tumors. Other causes include, but are not limited to: infectious diseases, nervous system lesions, psychiatric disorders, and medication.

How long do these symptoms last?

For the most part, the duration of AIWS symptoms seems to be relatively short, ranging from minutes to days. However, there are occurrences in which the symptoms lasted for years and sometimes for life!

How common is AIWS?

It’s hard to say, because we were unable to come across data on AIWS at large. However, it is generally assumed that AIWS is rare – some clinical studies amongst patients with migraine suggest that the prevalence rate could be around 15%.

AIWS is rarely diagnosed, partially because it is not included in major diagnostic manuals such as the ICD-10 or the DSM-5. Diagnosis of AIWS involves a combination of sound knowledge of the syndrome, its causes, a thorough neurological examination, and proper history taking. Brain scans can also aid in diagnosis – some research has shown that brain regions associated with visual activity are reduced in people reporting symptoms of AIWS.

Treating AIWS

Treatment of AIWS varies depending on the underlying cause. In many cases, reassurance alone may be enough to help people with the syndrome feel less alone. Of course, for the curative process to be the best it can be, it is vital that the clinician is aware of AIWS – it’s presenting signs, symptoms, possible underlying conditions, treatment to said conditions, and the side effects of these treatments. Usually, AIWS occurs during the active phase of the underlying condition which caused it to occur. It is also important that the clinician performs a careful assessment and is able to judge when it might be at everyone’s interest for the patient to be admitted to a healthcare facility.

Conclusion

Even though it has been over 6 decades since the syndrome was first identified and named, we have only recently begun to truly give AIWS the medical attention it deserves. One reason for recent interest is attributed to recent advancements in brain imagining. However, we have much more to learn about AIWS, such as how to prevent its occurrence and predict when it will occur. Given that we don’t truly understand the syndrome, we should direct some effort towards improving our understanding of it. Maybe then, a medical student will be able to read it off a reference and not stumble upon it like I did…

Interested in learning more about AIWS? I have written a 56-page book on it that you can purchase here.

Hassan is a medical student of Napata College in Khartoum – Sudan. Back in 2018, Hassan published his first scientific paper titled “Fatal Familial Insomnia” in IJSRP with Dr. Mazin S. Abdalla; Dr. Abdalla played a major role in introducing Hassan to the world of scientific research. As of this writing, Hassan has published 2 scientific papers in addition to the aforementioned titled “BIID: What do we know?” which was published in the British journal IJRP back in June of 2018 and “AIWS: Introduction, Overview and Literature Review” which was published in IJSRP back in February 2019, respectively. Hassan has also recently published a book titled “The Alice in Wonderland Syndrome: Based on a true story”. Hassan has also been a co-founder and executive in NMSA (Napata Medical Students’ Association). As a Sudanese medical student who grew up in the Kingdom of Saudi Arabia, Hassan has been associated with numerous cultures.

References:
(1) Carroll, L. (1865) Alice’s Adventures in Wonderland.
(2) Blom, J. D. (2016). Alice in Wonderland syndrome: A systematic review. Neurology: Clinical Practice6(3), 259-270.
Note: A full list of references appears in this article.
(3) Todd, J. (1955). The syndrome of Alice in Wonderland. Canadian Medical Association Journal73(9), 701-704.
(4) Osman, H. I. & Elmardi, D. F. (2019). AIWS: Introduction, overview and literature review. International Journal of Scientific and Research Publications, 9(2), 129-132.

Images:
(1) Wikipedia Commons.
(2)Flickr. Retrieved from https://www.flickr.com/photos/garlandcannon/5955733623.