Alice in Wonderland syndrome: An imitator of psychosis and other medical conditions

To the Editor

Alice in Wonderland Syndrome (AIWS) is a disturbance of perception leading to distortions of body, time and space. We present a 20-year-old man with a history of infrequent migraines since childhood. His general practitioner (GP) referred him for management of a first moderately severe depressive episode of 2 months duration, with no psychiatric history. He responded well to duloxetine 60 mg daily. During follow-up, the patient described having intermittent micropsia and macropsia, lasting up to 30 minutes. These began at age 5 and frightened him as a child, until he realised they were not real. Both perceptual disturbances and migraines diminished with age in frequency and intensity. They now occurred every 3 months and did not impair psychosocial function. However, he remained puzzled about his symptoms and worried about its significance. Mental state examination revealed excellent insight and an absence of thought disorder, hallucinations and delusions. Neurological examination was unremarkable.

Investigations to exclude causes of AIWS including full blood examination, electrolytes, liver function, vitamin B12, folate and thyroid function were unremarkable. Epstein–Barr virus (EBV) serology, Influenza H1N1 antibodies and Borrelia burgdorferi antibodies were negative. Electroencephalogram and magnetic resonance imaging (MRI) of the brain were unremarkable. The patient was reassured when education about AIWS and relationship to migraines was provided.

First described in 1955, AIWS is a rare disorder with 169 cases described in the literature (Blom, 2016). The cardinal symptoms are alterations in body size perception, with head and hands often seeming disproportionate. Perceptual disturbances can also occur in relation to objects, time and distance. Stationary objects may appear to move (kinetopsia) and straight lines may appear wavy (dysmorphopsia). Unlike hallucinations, AIWS involves perceptual distortions of actual stimuli. Symptoms usually occur at night.

AIWS is associated with migraines, temporal lobe epilepsy, brain tumours, EBV and psychoactive drugs. Sensory integration dysfunction in the temporoparietal-occipital carrefour has been postulated as causative (Mastria et al., 2016). AIWS has no proven treatment. Most cases spontaneously remit or vary in outcome depending on the underlying condition. Treatment usually involves reassurance and management of underlying conditions.

AIWS can be distinguished from schizophrenia on the characteristic nature of perceptual disturbances, absence of thought disorder and delusions, good insight and age of onset usually in childhood (Montastruc et al., 2012). This is important in providing patients an accurate diagnosis, prognosis, reassurance and avoiding antipsychotics, which are ineffective. Finally, investigations can be initiated by the psychiatrist to exclude medical causes of AIWS.