A report of Alice in Wonderland syndrome in schizophrenia

Introduction

Alice in Wonderland syndrome (AIWS) is a disorder of perception marked by visual distortions, altered passage of time and morphed body schema. AIWS is derived from the famous 19th-century work of art by Lewis Carroll’s ‘Alice’s Adventures in Wonderland’. Alice experiences various situations of altered perception like micropsia and macropsia (Todd, 1955).

Such phenomenology is usually secondary to conditions like migrainous aura, arterio-venous malformation, focal seizures, hyperpyrexia, neoplasm, psychoactive substance use and infectious mononucleosis and other organic conditions.

Description of such syndrome associated with functional psychosis like schizophrenia is rarely described in the literature. Hereby, we report a case of schizophrenia presenting with AIWS.

Case description

Mrs K, a 30-year-old female, was brought to the psychiatry OPD with complaints of suspiciousness, irritable behavior, decreased sleep and decline in household work.

During mental status examination, it was revealed that she used to see her son in a miniature form, she tried to catch hold of him and keep it under protection else some insect or rodent may harm him. The image was in external space, vivid and involuntary. Delusion of infidelity for her husband was observed.

Patient’s psychiatric history and personal and family history were unremarkable and she was well adjusted premorbidly. Her medical history was unremarkable.

No abnormality was detected during general and systemic examination. Investigations including hemogram, liver and renal function tests, electroencephalography (EEG), magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) of brain did not reveal any pathological findings. Ocular and fundus examination were normal.

A diagnosis of paranoid schizophrenia was formulated as per Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). Patient was treated with olanzapine, and at a dose of 20 mg, her symptoms decreased significantly over 2 months.

Discussion

Most cases of AIWS are reported secondary to organic causes like infections, epilepsy and migraine. In the index case, organicity was ruled out through meticulous examination and investigations.

Patient fulfilled the clinical criteria for schizophrenia. Visual hallucinations in schizophrenia are perceived as vivid experiences and usually involve normal-sized people and objects; however, rarely visual hallucinations of giants and Lilliputians have been reported. Some researchers explained AIWS through a functional disconnection between primary and association visual cortices as a result of schizophrenic neurobiology and circuits (Chand and Murthy, 2007).

Presentation of AIWS with schizophrenia is an interesting finding from phenomenological perspective. Further research can shed light on the underlying biological substrates for this association.