Alice in Wonderland syndrome (AIWS), also known as Todd’s syndrome or Lilliputian hallucinations, is a perception disorder. The popular name was coined because the symptoms are similar to what Alice experiences when she travels to Wonderland. Some speculate that the author of Alice in Wonderland, Lewis Carroll, experienced migraines and was have been inspired by his own auras and distortions.

Lack of Diagnostic Criteria

Alice in Wonderland syndrome remains poorly understood and often misdiagnosed. It can happen to anyone at any age and is not solely related to any single medical condition, though there appears to be a strong link with migraines. Researches have not developed standard diagnostic criteria, so there is a lot of variability in the diagnosis.

Symptoms Overview

Alice in Wonderland syndrome has visual and nonvisual symptoms. They are classified as distortions of perception as opposed to illusions or hallucinations. The latter occur without stimulus from the outside world, like hearing a voice that is not there. Illusions do have a source in the outside world, but it is misinterpreted; for example, seeing a jacket hanging over a chair and thinking it is a person. Distortions are similar in that, like illusions, they come from an outside stimulus, but they feature specific changes in perception.

Visual Distortions

There are 42 specific visual distortions identified as symptoms of Alice in Wonderland syndrome. These include

• arugopsia — seeing rough surface as smooth
• dymorphopsia — when straight lines appear wavy
• inverted vision — when objects appear rotated
• loss of stereoscopic vision — when objects appear two-dimensional

People with AIWS may also experience macropsia or micropsia, when objects appear larger or smaller than they are, respectively.

Nonvisual Distortions

Sixteen nonvisual or somesthetic distortions have been identified in Alice in Wonderland syndrome. They include partial macro or micro asomatognosia, which is experiencing a part of the body as larger or smaller than it really is, protracted duration or the deceleration of time, quick-motion phenomenon or the acceleration of time, and total-body macro or micro asomatognosia or experiencing the entire body as larger or smaller than it really is.

Duration of Symptoms

The symptoms of Alice in Wonderland syndrome do not appear simultaneously. In most cases, the duration of symptoms lasts between five and 20 minutes, but in some cases, they may last for years or even a lifetime. Some researchers question whether some symptoms, like time loss, result from the condition that is causing AIWS rather than the syndrome itself.

Prevalence

There are no universally accepted diagnostic criteria or large-scale studies on Alice in Wonderland syndrome, so its prevalence is unknown. Studies suggest that 65 percent of all cases occur in children under the age of 18. Between five and 14, males are more likely to experience AIWS, but by 15, there is no significant difference in prevalence between males and females. After 16, females are significantly more likely to experience it.

Migraines

Migraine is the number one cause of Alice in Wonderland syndrome in adults and the second leading cause in children. Diagnostic criteria have been proposed for migraine-associated AIWS but are not yet generally applied. These criteria consist of one or more distortion episodes lasting less than 30 minutes and accompanied by a headache or history of migraines. One study demonstrated that some children developed symptoms of AIWS up to a year before their first migraine.

Infections

The most common cause of Alice in Wonderland syndrome in children is acute infection. In some studies, however, children presenting with infection also reported headaches, meaning that researchers could not rule out a migraine connection. Epstein-Barr, a virus in the herpes family, is the most commonly reported pathogen causing AIWS in children. Some reports show periodic slowing of electrical activity on an EEG in some patients with AIWS due to infection.

Other Causes

In addition to migraine and infection, there are many other potential causes of Alice in Wonderland syndrome. They include various forms of epilepsy, hemorrhagic and ischemic stroke, glioblastoma, and pituitary infarction. Several psychiatric disorders, like depressive disorder, schizophrenia, and schizoaffective disorder, may also cause AIWS. In addition to Epstein-Barr, infectious causes include cytomegalovirus, varicella-zoster, scarlet fever, and influenza A.

Treatment

Most cases of Alice in Wonderland syndrome are benign, and symptoms resolve completely and spontaneously. In other cases, when AIWS is believed to be related to an underlying condition like epilepsy or migraine, symptoms reappear during active phases of the condition. If treatment is necessary, it is aimed at resolving the underlying condition.