Alice in Wonderland in the Brain: When Perception Goes Haywire
The Alice in Wonderland Syndrome (AIWS) is a rare neurological disorder that causes profound perceptual distortions. Affected individuals experience episodes in which objects or body parts appear significantly larger (macropsia) or smaller (micropsia) than they actually are. Distances and spatial dimensions may also be perceived differently (pelopsia, teleopsia). Some people also report a disturbed sense of time or the feeling of being split into two individuals. These symptoms are not due to visual or auditory problems, but rather to a misprocessing of sensory signals in the brain.
The syndrome was first described in the 1950s and was named after Lewis Carroll’s famous fictional character Alice, who experiences similar perceptual changes in Wonderland. AIWS often occurs in connection with migraines, especially migraine with aura. About 20% of patients with this type of migraine have experienced such perceptual changes, frequently occurring just before a migraine attack.
However, AIWS can also be triggered by other causes such as viral infections, epilepsy, or certain medications. In children, the syndrome is particularly common following an infection with the Epstein-Barr virus.
Despite growing scientific interest, there are currently no established diagnostic criteria for AIWS in medical classifications such as ICD-10 or DSM-5. Diagnosis is made by ruling out other conditions and recognizing the typical symptoms. While most people experience only occasional episodes, in some cases the symptoms can persist over longer periods. Despite the bizarre perceptual changes, the awareness that these sensations are unreal typically remains intact.
Scientific Findings and Current Research
Charité Berlin investigated the prevalence of AIWS in people with migraines. Of 808 patients surveyed, 17% reported experiencing AIWS symptoms at least once in their lives. Micropsia and teleopsia - the perception of objects as smaller or farther away - were especially common. Migraine patients with aura reported AIWS episodes more frequently than those without aura (20% vs. 14%). However, aura was not a necessary condition, as nearly half of those affected did not suffer from aura migraines.
In addition to visual distortions, many reported altered body perception (micro- or macrosomatognosia), feelings of detachment, and distorted time perception. On average, AIWS episodes lasted 38 minutes and often occurred before, during, or after a migraine attack. Some sufferers experienced anxiety or sadness during episodes, while others reported an unusual sense of euphoria.
Since AIWS symptoms resemble those of a migraine aura, researchers suspect that similar mechanisms may be responsible. A possible explanation is cortical spreading depression - waves of neuronal depolarization occurring in migraine auras - which may cause different perceptual distortions depending on the brain region affected. However, the exact causes remain largely unknown.
A bibliometric analysis of 125 scientific articles (1900–2019) showed that interest in AIWS has increased significantly since 2008. Most publications originate from the USA, Japan, Italy, and Germany. The research mainly focuses on the relationship between AIWS and migraines as well as infections, particularly those caused by the Epstein-Barr virus and influenza. However, there are still few studies on diagnosis and treatment, highlighting the need for further research.
Case Report: AIWS Following Stroke and Epilepsy
A special case involving a 69-year-old man illustrates the complexity of the Alice in Wonderland Syndrome. After an ischemic stroke in the right occipital lobe, the patient suffered from visual hallucinations. He intermittently perceived people and objects as distorted: sometimes larger, sometimes smaller, and his own body size seemed to change. He also experienced color perception disturbances. MRI scans revealed progressive ischemic damage, while an EEG showed focal epileptic activity.
After treatment with levetiracetam, a medication for epilepsy, the symptoms initially improved. But a few weeks later, the patient developed uncontrollable twitching in his left leg, while remaining fully conscious. A follow-up EEG showed that these movements correlated with epileptic discharges in the right hemisphere. The diagnosis was epilepsia partialis continua, a special form of focal status epilepticus. After treatment with phenytoin, another antiepileptic drug, both the seizures and the AIWS symptoms disappeared.
This case demonstrates that AIWS can be associated not only with migraines but also with epileptic seizures and strokes. The distorted sensory perceptions likely resulted from epileptic activity in the affected brain regions.
The Alice in Wonderland Syndrome is a rare neurological condition that remains poorly understood. It occurs more frequently in connection with migraines, epilepsy, and infections than previously assumed. While the symptoms are usually temporary, they can persist in rare cases. Science is still in its early stages, but initial insights into the underlying neural mechanisms may lead to improved diagnostic and therapeutic approaches in the future.
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