Alice in Wonderland Syndrome

Alice in Wonderland syndrome is one of the most fascinating neurological symptoms described in the medical literature. Estimated to occur among about 10-20% of the population, Alice in Wonderland syndrome is an infrequent event that is believed to occur only a few times throughout the lives of most affected individuals. It is an experience that people can describe with varying levels of detail, the consistent feature being a fleeting sense of dystrophism without associated long-term or short-term disability.

Descriptions of Alice in Wonderland syndrome 

Case reports illustrate a cluster of related symptoms. Most often, a perception of becoming physically smaller or physically larger in comparison to surroundings is the central detail. However, there may be an impression that a person's surroundings are growing or shrinking rather than the person himself. Other narratives include distortions in visual awareness, including the sense that fixed surroundings are moving. 

Alice in Wonderland syndrome and associated medical conditions 

Given the fleeting passage of the experience and the lack of major medical issues associated with the perceptual peculiarities, it is difficult to ascertain with certainty whether Alice in Wonderland syndrome affects more people than the numbers estimated in the medical literature. Most people who experience it would be unlikely to report it to a medical professional without a reason. 

Among adults, people who have migraine, epilepsy, or head trauma are the most likely to report Alice in Wonderland syndrome. Alice in Wonderland syndrome in the context of migraine aura is by far the most prevalent association described on adults. Children who relay the features of Alice in Wonderland syndrome are noted to have an approximately 50% chance of developing a subsequent infection and a very high likelihood of developing migraine headaches as they get older. 

Often, it is neurologists or psychiatrists who inquire about alterations of perception, rather than patients initiating the details themselves. Therefore, the correlation between Alice in Wonderland syndrome and migraine could be the result of leading questions in the patient history. For example, in casual conversation with neurologists, the percentage that recalls a personal experience with Alice in Wonderland syndrome is substantially higher than expected among the general population, which may be a product of awareness of the fact that the perceptual event has an identity and a name. 

Overall, despite the unusual perceptions, what is most important about this syndrome is that the fleeting symptoms are not predictive of mental illness or of cerebrovascular disease, which are undeniably the most concerning issues for patients and health care providers when it comes to strange perceptions.

It is important to consider that while unprovoked and fleeting, Alice in Wonderland syndrome is not usually the sign of neurological illness. However, persistent symptoms should raise a red flag as a possible sign of an occipital lobe lesion or of intoxication with a substance that could impact the central nervous system.

Would you consider a toxicology screen or neuroimaging the right approach in the workup of a patient who has experienced perceptual abnormalities with resolution of symptoms?

References:

Blom JD. Alice in Wonderland syndrome: a systematic review. Neurol Clin Pract. 2016 Jun;6(3):259-270.

Rastogi RG, et al. Migrainous aura, visual snow, and “Alice in Wonderland” syndrome in childhood. Semin Pediatr Neurol. 2016 Feb;23(1):14-17.