Alice in Wonderland and Ekbom Syndromes in a Bipolar I Manic Episode: A Case Report With Neuroimaging Findings

Alice in Wonderland Syndrome (AIWS) is named after a novel that was written by Lewis Carroll. The condition was first illustrated in 1955 by John Todd, a psychiatrist. Todd named it, for Alice's Adventures in Wonderland by Lewis Carroll. Perchance, Lewis Carroll suffered from severe migraine and the disorder as well. Alice in Wonderland Syndrome is a disorienting condition that affects one’s perception. AIWS is a neurological disorder that disturbs signals that are sent from the eyes to the brain, thereby causing a subsequent distortion in perception. The patients complain of visual, auditory and tactile hallucinations and altered perceptions. Alice in Wonderland Syndrome in childhood is very rare and can be baffling and terrifying for the patient; for he feels he is going mad in a weird world with warped perceptions and hallucinations. The causes for AIWS are still not known exactly. Migraine, temporal lobe epilepsy, brain tumors, depression, toxic and febrile delirium, psychoactive drugs, ischemic stroke and infections with EBV, mycoplasma and malaria are related features of AIWS. Neuroimaging studies reveal brain regions including the temporoparietal junction, the temporal lobe and the visual pathway, the occipital lobe. Abuse was yet not mentioned in this entity.

Research objectives: Alice in Wonderland syndrome (AIWS) is a perceptual disorder characterized by distortions of visual perception (metamorphopsias), the body schema and the experience of time. The aim of this study is to summarise the current state of knowledge about this disease. Methods: The PubMed database was searched using the term: ”Alice in Wonderland Syndrome”. After analysis, 34 papers were included in the review. Key findings: Affected individuals can experience visual illusions, including dysmetropsia, namely micropsia (objects appear small), macropsia (objects appear large), teleopsia (objects appear further away than they are). In addition to these alterations in perception, patients might have distorted experience of time, disorders of consciousness such as feelings of derealization, depersonalization. There are numerous disorders, intoxications and other conditions that have been described in the context of AIWS. In childhood, AIWS is most commonly linked with migraine and encephalitis caused by Epstein–Barr virus. Migraines are frequently thought to be the main cause in adults. Other possible underlying conditions of the AIWS include infections, epilepsy and intoxications.Treatment must be directed toward the presumed underlying disease whenever it is deemed necessary and beneficial. Conclusions: Alice in Wonderland syndrome is still poorly known condition and probably misdiagnosed for the lack of clear and universally accepted diagnostic criteria. It can occur at any age, but appears to be more common during childhood and adolescence. The most common symptoms include: distortions of the size, mass or shape of the patient’s own body.

Possible Association Between Alice In Wonderland Syndrome And Influenza A Infection

The phenomenon of Alice in Wonderland Syndrome is not considered a disease in its own right but usually occurs as an accompanying symptom of a migraine attack or as a precursor of an epileptic seizure in the form of an aura with pronounced visual perceptual disturbances [1]. However, an Alice in Wonderland syndrome can also be caused by the Epstein-Barr virus, influenza virus [18], drugs [3] or encephalitis [2]. The term "Alice in Wonderland syndrome" was named after the children's book Alice in Wonderland by Lewis Carroll and coined by John Todd as a possible, but not essential, concomitant of migraine and epilepsy [1]. Carroll suffered from migraines himself; it is believed that his experiences with the condition served as inspiration for the hallucination-like effects described in his work [1]. In addition, Carroll's narrative has been discussed as a description of a trip following consumption of mind-altering drugs. In one of the most famous sequences in the book, Alice changes size by biting off pieces from different sides of a mushroom. However, there is no evidence of drug use by Lewis Carroll. Alice in Wonderland syndrome results in changes in the perception of one's surroundings [6,7]. These changes include both micropsia and macropsia (everything appears reduced or enlarged), as well as altered auditory perception, altered tactile perception, an altered sense of time. The syndrome is particularly common in children. Attacks are often shorter and may also be completely painless, although accompanying symptoms such as nausea, vomiting, and sensitivity to light and sound is more pronounced. Neurological deficits may occur so that the affected child begins to hallucinate. He or she perceives his or her body as larger or smaller and/or begins to see "fantastic images“. The changes in perception can severely affect affected individuals, causing them to become disoriented and "unable to find their way around." In extreme cases, falls and other accidents may occur. The perceptual disturbances can lead to Alice in Wonderland syndrome being confused with other mental disorders or misinterpreted as "craziness". The primary focus is the treatment of the underlying condition, such as symptomatic treatment of migraine. Recent publications shed light on sexual abuse in childhood as the origin of AIWS-like visual disturbances [4,5].

Alice in Wonderland syndrome (AIWS), named for Lewis Carroll’s titular character, is a disorder characterized by transient episodes of visual hallucinations and perceptual distortions, during which objects or body parts are perceived as altered in various ways (metamorphopsia), including enlargement (macropsia) or reduction (micropsia) in the perceived size of a form. Migraine aura is a transient neurological symptom that most commonly involves the visual fields and occurs before the headache phase. Aura symptoms include the perception of flashing lights that begin in the center of vision and expand in jagged patterns out into the periphery. Symptoms may be somatosensory, such as numbness and tingling in the lips or fingers. They may also involve a profound alteration of the perception of space and time (the “Alice in Wonderland” syndrome). In this article, we present a child had Alice in Wonderland syndrome as aura of migraine.

Alice in Wonderland Syndrome (AIWS) was named after the description of Lewis Carroll in his novel. In 1955, John Todd, a psychiatrist described this entity for the first time. Todd described it as “Alice's Adventures in Wonderland” by Lewis Carroll. The author Carroll suffered from severe migraine attacks. Alice in Wonderland Syndrome is a disorienting condition of seizures affecting the visual perception. AIWS is a neurological form of seizures influencing the brain, thereby causing a disturbed perception. Patients describe visual, auditory and tactile hallucinations and disturbed perceptions. The causes for AIWS are still not known exactly. Cases of migraine, brain tumors, depression episodes, epilepsy, delirium, psychoactive drugs, ischemic stroke, EBV, mycoplasma and malaria infections are correlating with AIWS like seizures. Neuroimaging studies reveal disturbance of brain regions including the temporoparietal junction, the temporal lobe and the occipital lobe as typical localization of the visual pathway. We present the case of a 17 years-old teenager from Canada, who describes his experience with AIWS-like visual disturbances in detail. The case report shed light on the presence of a lying position in Alice in Wonderland like visual sensations.

Migraine affects how the brain processes sensory information at multiple levels. The aberrant integration of visual and somatosensory stimuli is thought to underlie Alice in Wonderland Syndrome, a disorder often reported as being associated with migraine. However, there is still a lack of knowledge about the epidemiology of this syndrome in migraineurs and the association between Alice in Wonderland Syndrome episodes and migraine attacks. Therefore, we conducted a prospective cohort study to systematically evaluate the prevalence and the clinical features of Alice in Wonderland Syndrome in a large sample of patients with migraine. All the patients attending for the first time a tertiary-level headache clinic were consecutively screened for Alice in Wonderland Syndrome symptoms by means of an ad hoc questionnaire and detailed clinical interview, over a period of 1.5 years. Patients experiencing Alice in Wonderland Syndrome symptoms were contacted for a follow-up after 8-12 months. Two hundred and ten patients were recruited: 40 patients (19%) reported lifetime occurrence of Alice in Wonderland Syndrome, 90% of whom (38/40) had migraine with aura. Thirty-one patients experienced episodes of Alice in Wonderland Syndrome within 1 h from the start of migraine headache. Patients reported either visual or visual and somatosensory symptoms (i.e. somatosensory symptoms never presented alone). We collected the follow-up details of 30 patients with Alice in Wonderland Syndrome, 18 of whom had been prescribed a preventive treatment for migraine. After 8-12 months, 5 of the treated patients reported a decrease, while 13 reported no episodes of Alice in Wonderland Syndrome. Alice in Wonderland Syndrome prevalence in migraineurs was found to be higher than expected. Alice in Wonderland Syndrome was mostly associated with migraine with aura and tended to occur close to the migraine attack, suggesting the existence of a common pathophysiological mechanism. Patients treated with migraine preventive treatments had a higher chance of decreasing or even resolving Alice in Wonderland Syndrome episodes.

Alice in Wonderland Syndrome: A real life version of Lewis Carroll’s novel

Alice in Wonderland Syndrome is a rare neurological condition temporarily cause distortion in perception of body size, image and time can lead to disorientation and misperception of reality. The syndrome is usually associated with visual hallucinations. It is very rare condition most often affect in children and young adult. It is due to family history of migraines, temporal lobe epilepsy, delirium tremens, and brain tumors, Infectious mononucleosis. The hallmark sign of Alice in Wonderland syndrome is a migraine. No proven effective treatment for Alice in Wonderland syndrome (AIWS). Plenty of rest, Migraine treatments can help stop symptoms and prevent future attacks of “Alice in Wonderland Syndrome.”

Alice in Wonderland syndrome is a process characterized for complex disorders of the visual perception with multiple etiologies. To evaluate the clinical, electrophysiological, etiological characteristics and natural evolution in children with Alice in Wonderland syndrome. We have realized a retrospective study by what means of a review of 20 clinical histories of 18 year old minor patients diagnosed of Alice in Wonderland syndrome from January 1995 until February 2010. The average of age to the diagnosis was 9.5 ± 3.8 years (range: 4-16 years). It appeared in an acute way in 85% and progressive in 15%. 90% had micropsias and/or macropsias, 85% distortion of the form of the objects, 80% displacement of objects, 45% disturbances of body image, 45% acceleration of the time and 30% sensation of unreality. 95% of the children had many episodes a day; these episodes lasted less than 3 minutes in 90%. Electroencephalogram was realized in all the patients, it was abnormal in 11 cases, in one case was found and epileptic foci (left temporal) and in 10 cases was found posterior slow waves. The tests of neuroimagen were normal in all the patients. The visual evoked potentials were realized in 7 children; five of these children showed higher amplitude in evoked potentials and two of these children had normal. The infectious etiology was found in nine cases (five partners to Epstein-Barr virus), migraine in eight, toxins in two and epilepsy in one case. 80% did not have recurrence. Alice in Wonderland syndrome is a benign process with trend to spontaneous resolution and without recurrence in the majority of the occasions. The principal etiologies are migraine and Epstein-Barr virus infection.

ObjectiveAlice in Wonderland Syndrome (AIWS) is a sensory disorder characterized by a distorted somatosensory and/or visual perception. Additionally, distortion of time perception and symptoms of derealization/depersonalization may occur. AIWS is frequently associated with migraine. However, its prevalence, and clinical characteristics remain poorly understood. Here, we investigated the prevalence and features of AIWS in individuals with migraine. We hypothesized AIWS is more frequent in migraine patients with aura than in those without aura.MethodsThis was a prospective cross-sectional cohort study, conducted at a tertiary headache center. Participants with migraine filled out questionnaires, providing details on demographics, headache, AIWS characteristics and the occurrence of transient visual phenomena such as fragmented vision.ResultsOf 808 migraine patients, 133 individuals (16.5%, mean age 44.4 ± 13.3 years, 87% women) reported AIWS symptoms throughout their lives. Micro- and/or telopsia (72.9%) were most frequent, followed by micro- and/or macrosomatognosia (49.6%), and macro- and/or pelopsia (38.3%), lasting on average half an hour. AIWS symptoms occurred in association with headache in 65.1% of individuals, and 53.7% had their first AIWS episode at the age of 18 years or earlier. Migraine patients with aura were more likely to report AIWS symptoms than those without aura (19.5% vs. 14.1%, p = 0.04). Participants with AIWS reported a higher incidence of 17 out of the 22 investigated visual phenomena.ConclusionAIWS symptoms appear to be a common lifetime phenomenon in migraine patients. The correlation and clinical parallels between AIWS and migraine aura could indicate shared underlying pathomechanisms.

Various visual and sensory phenomena have been described in migraine with aura. Among those, the “Alice in Wonderland” syndrome is defined as a distortion of the body image with the...

To the Editors: We reported a case of Alice in Wonderland syndrome caused by the 2009 pandemic H1N1 influenza virus, confirmed by elevated antibody titers on a hemagglutinin inhibition assay. The case was a 5-year-old girl. She was previously healthy and had no history of convulsions or headache. She visited her family doctor complaining of a high fever on the second day of sickness in September 2009 and was diagnosed with influenza A infection proved by a rapid test for influenza. She was given oseltamivir for 3 days, and her clinical signs and symptoms disappeared after the initiation of therapy on the seventh day. She complained of micropsia and macropsia. The micropsia and macropsia were subjective complaints, and an examination by our ophthalmologist revealed no abnormality. Neurologic studies including EEG, brain magnetic resonance imaging (3 Tesla) followed by single-photon emission computed tomography showed normal results. There was no recent history of Epstein-Barr virus (EBV), chickenpox, or intestinal viral infection. Laboratory tests on admission revealed a white blood cell count of 9100/μL (44.1% segmented, 6.7% eosinophils, 5.2% monocytes, 43.7% lymphocytes, 0.3% basophils, and no atypical lymphocytes), hemoglobin 14.0 g/dL, and platelet count 319,000/μL. The serum glucose level was 85 mg/dL, aspartate aminotransferase 36 U/L, alanine aminotransferase 17 U/L, sodium 138 mmol/L, potassium 4.6 mmol/L, and chlorine 106 mmol/L. Biochemical markers for a severity of inflammation revealed a normal C-reactive protein (<0.1 mg/dL) with normal levels of lactic dehydrogenase and creatinine kinase. A routine urinalysis showed normal results. Serologic studies revealed EBV-IgM 0.8 (normal: approximately 0.5) and EBV-IgG 0.5 (normal: approximately 0.5), cytomegalovirus-IgM 0.32 (normal: approximately 0.79), and cytomegalovirus-IgG 26.9 (normal: approximately 1.9). Laboratory blood investigations a month after the first visit to the family doctor revealed a hemagglutinin inhibition titer to the 2009 pandemic H1N1 influenza A virus >1:1024. The visual abnormalities disappeared spontaneously within 2 months. Alice in Wonderland syndrome is characterized by visual sensory abnormalities including micropsia and macropsia and they are regarded as a reflection of migraine or psychologic diseases. On the other hand, there have been several reports of this syndrome in cases with viral infections such as EBV,1 varicella,2 or coxsackie B1 virus.3 A case of Alice in Wonderland syndrome associated with H1N1 influenza was reported,4 while we were preparing this manuscript. The neurologic prognosis of Alice in Wonderland syndrome caused by several viral infections is good.2–4 Thus, Alice in Wonderland syndrome is completely different from encephalopathy caused by the 2009 pandemic H1N1 influenza.5 Also, this syndrome seemed to have no relation to neuropsychiatric side effects of neuraminidase inhibitors such as osertamivir or zanamivir. No cases of Alice in Wonderland syndrome attributable to these drugs have been reported in Japan where neuraminidase inhibitors are common medications for seasonal influenza infection. The clear mechanism for a correlation of Alice in Wonderland syndrome to the 2009 pandemic H1N1 influenza remains to be elucidated. Hirohumi Nakaya, MD Takehisa Yamamoto, MD Mika Takano, MD Katsusuke Yamamoto, MD Department of Pediatrics Minoh City Hospital Yasuhiro Hujikawa, MD Division of Pediatrics Hujikawa children's clinic Osaka, Japan Saeko Morikawa, DVM Tetsuo Kase, PhD Department of Virology Osaka Prefectural Institute of Public Health Osaka, Japan Tsunesuke Shimotsuji, MD Department of Pediatrics Minoh City Hospital Osaka, Japan

The Alice in Wonderland Syndrome (AIWS) is an unusual and uncommon condition that falls under the umbrella of neurology and psychiatry. It is characterized by the presence of complex perceptual and visual discord. Additionally, there are visual hallucinations that are multi-dimensional. This syndrome was first described by John Todd in the 1950s, and it was loosely based on the book Alice in Wonderland. A man in his 30s arrived at his doctor’s appointment with a chief complaint of a pounding cluster headache that lasted over a full day. In addition, he mentioned that there was an aura preceding his headaches. The pain was so intense, it was debilitating him from routine activities. Before the headaches, he explained that he would sense bizarre physical and visual behaviors. During these episodes, he explained that things around him appeared distorted and of various sizes. Things in his room appeared to be more distant than they really were and larger in size (macropsia and micropsia). He described the fingers on his right hand to be much smaller compared to his left hand (micropsia). Objects around him were deformed and distorted (metamorphopsia). His symptoms lasted 45 minutes. He did not suffer from any previous headaches or hallucinations. He was a healthy man with a clean bill of health as per his medical records. Upon examination, the attending physician described the patient as alert, oriented to time and place, and under no obvious distress. All labs performed returned normal including a 10-panel drug test. These were tested to see if he was under the influence of any narcotic, stimulant, or other substances. The physician prescribed 500 mg of valproic acid to take daily. Three months later during his follow-up, he mentioned his symptoms had subsided but were still present. His dose was again increased to 1000 mg/day, eventually stopping all further symptoms from surfacing. He has not had another episode in three months. The Alice in Wonderland Syndrome is known to be associated with headaches with preceding auras. It is common in the pediatric and adult populations. In this paper, I introduce a case of a patient who displays migraines with preceding auras, indicative of AIWS.

Lewis Carroll wrote in 1864 the novel of Alice in Wonderland “Alice`s Adventures under Ground” [1]. The British psychiatrist John Todd (1914-1987) described the curious condition of micro-and macrosomatognosia, altered perceptions of body image, and described it as Alice in Wonderland Syndrome. John Todd described it 1955 and gave it the literary name in his publication