Alice in Wonderland Syndrome

1. ALICE IN WONDERLAND
SYNDROM
Ade Wijaya, MD – January 2019

2. Introduction
• First described in 1955 by the British psychiatrist
John Todd
• A perceptual disorder characterized by distortions
of visual perception (metamorphopsias), the body
schema, and the experience of time
• Rare
• Distortions of sensory perception rather than
hallucinations or illusions
Carroll L. Alice’s Adventures in Wonderland. London: MacMillan and Co.; 1865
Todd J. The syndrome of Alice in Wonderland. Can Med Assoc J 1955;73:701–704.
Restak RM. Alice in migraineland. Headache 2006;46:306–311.
Carmichael C. Wonderland revisited. London Miscellany 1996;28:19–28.
Smith RA, Wright B, Bennett S. Hallucinations and illusions in migraine in children and the Alice in Wonderland syndrome. Arch Dis Child 2015;100:296–298
Blom JD. A Dictionary of Hallucinations. New York, NY: Springer; 2010

3. Etiology
• Infectious disease
• CNS lesions
• PNS lesions
• Paroxysmal neurologic disorders (epilepsy,
migraine)
• Psychiatric disorders
• Medication
• Substance-induced
• Miscellaneous
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

4. Infectious Diseases
• Coxsackie B1 virus encephalitis
• Cytomegalovirus
• Epstein-Barr virus encephalitis (mononucleosis
infectiosa)
• Influenza A virus encephalitis
• Lyme neuroborreliosis
• Scarlet fever
• Typhoid encephalopathy
• Varicella-zoster encephalitis
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

5. CNS Lesions
• Acute disseminated encephalomyelitis
• Cavernous angioma
• Cerebral arteriosclerosis
• Cerebral thrombosis
• Cerebral hemorrhage
• Cerebral infarction
• Brain tumor
• Microembolization after open heart surgery
• Robin Hood syndrome
• Traumatic encephalopathy
• Wallenberg syndrome
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

6. Psychiatric disorders
• Depressive disorder
• Derealization/depersonalization disorder
• Misidentification syndrome
• Schizophrenia
• Schizoaffective disorder
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

7. Medications
• 5-HT2 antagonist
• Dextromethorphan
• Cough syrup (containing dihydrocodeine and DL-
methylephedrine)
• Montelukast
• Oseltamivir
• Risperidone
• Topiramate
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

8. Substance-induced
• Amanita muscaria
• Amphetamines
• Ayahuasca
• Cannabis
• Cocaine
• LSD
• MDMA
• Mescaline
• Toluene-containing solvent
• Trichlorethylene
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

9. Miscellanous
• Hypnagogic state
• Hypnopompic state
• Hypnotherapy
• Hyperpyrexia
• Sensory deprivation
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

10. Visual Distortions (Metamorphopsia)
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

11. Visual Distortions (Metamorphopsia)
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

12. Visual Distortions (Metamorphopsia)
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

13. Visual Distortions (Metamorphopsia)
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

14. Somesthetic and Other Nonvisual Distortions
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

15. Pathophysiology
• Functional and structural aberrations of the
perceptual system
• Most prevalent: central pathology
• In some cases: retinal or labyrinth pathology
ffytche DH, Howard RJ. The perceptual consequences of visual loss: “positive” pathologies of vision. Brain 1999;122:1247–1260.
Deecke L, Mergner T, Plester D. Tullio phenomenon with torsion of the eyes and subjective tilt of the visual surround. Ann NY Acad Sci 1981;374:650–655

16. Diagnosis
• History taking
• A thorough physical (including neurologic and often
otologic and/or ophthalmic) examination
• Blood tests
• EEG
• Brain MRI
Liu AM, Liu JG, Liu GW, Liu GT. “Alice in Wonderland” syndrome: presenting and follow-up characteristics. Pediatr Neurol 2014;51:317–320

17. Treatment and Prognosis
• Usually benign
• Treat underlying conditions
Blom JD. Alice in Wonderland syndrome: a systematic review. Neurology: Clinical Practice. 2016 Jun 1;6(3):259-70.

18. Summary
• Distortions of sensory perception
• Various etiology
• Visual and non visual distortions
• Treat the underlying cause