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Down the rabbit hole: Alice in Wonderland syndrome

MDlinx May 15, 2024

Patients with Alice in Wonderland syndrome (AIWS) see the surrounding world far differently from those around them. Sensory distortions cause AIWS patients to see objects smaller or larger than they actually are—including parts of their own body.

Little is known about AIWS, and although more common than previously thought—especially among persons with migraine—the condition is still rare, according to authors writing in Psychiatry International.

Hernandez J. The perplexing mental health comorbidity of Alice in Wonderland syndrome (AIWS): a case study. Psychiatry Int. 2023;4(1):30–34.


Nevertheless, AIWS represents a fascinating look at how neuroanatomy can alter perceptual reality in odd and unusual ways. 




AIWS results in transitory events of distorted perception and disorientation (ie, metamorphopsias). Some of the distortions that patients experience include brief sensations of feeling smaller or larger than they really are, or perceiving the room in which they are located as appearing much larger or smaller than it actually is. The furniture may look distorted, as well. Importantly, this condition affects all senses and perceptions, including vision, touch, and hearing.

To the early researchers who identified the syndrome, “Patients with this syndrome described their physical frame as being altered in illusions with changes in forms, dimensions, and motions of objects,” note the authors in Psychiatry International.




AIWS is a diagnosis of exclusion and made using presenting signs and symptoms. No ICD-10 or DSM-5 criteria have been confirmed for the condition.

Etiologies include migraine, EBV or other viral infections, epilepsy, CNS lesions, and hallucinogenic substances. Up to 15% of patients with migraine exhibit this condition. One study found that nearly 50% of pediatric patients with AIWS had a family history of migraine, thus suggesting a genetic predisposition.

Overall, EBV infection is the most common cause of AIWS in children, whereas migraine is the most common cause in adults.

Investigations into the pathophysiological mechanisms underlying AIWS are limited. In cases where CNS lesions are the underlying etiology of AIWS, recent research has found that such lesions most commonly affect the extrastriate visual cortex. In cases of non-structural causes of AIWS, however, the role of a similar brain network has not been confirmed.

Mastria G, Mancini V, Viganò A, et al. Neuroimaging markers of Alice in Wonderland syndrome in patients with migraine with aura. Front Neurol. 2023;14:1210811.


In one study, investigators used lesion network mapping to test whether the location of lesions that cause AIWS fall within a common brain network, which was defined by connectivity to a specific set of distant regions.

Friedrich MU, Baughan EC, Kletenik I, et al. Lesions causing Alice in Wonderland Syndrome map to a common brain network linking body and size perception. Published online January 18, 2024. doi:10.1101/2024.01.17.24301332.


They found a brain network that connected two relevant brain regions: the right extrastriate body area, which becomes selectively activated by viewing body parts, and the inferior parietal cortex, which is involved in processing size and scale. 

“Taken together,” the investigators wrote, “we hypothesize that lesions causing AIWS, due to their specific connectivity profile, simultaneously disrupt two higher-order brain functions related to body perception and judgement of size and scale.” 


Personalized treatment


Management of AIWS should be personalized, as there is no definitive medication regimen for the condition. The need for treatment is based on the natural course of underlying conditions. Specialists may consider prescribing migraine preventive medications, antibiotics, antivirals, or anti-epileptics, based on the cause. Most clinical cases of AIWS are benign and resolve spontaneously, or do so after treatment.

According to the Psychiatry International authors, verapamil is reported to be 55% effective in treating AIWS caused by migraine, whereas valproic acid provides 18% effectiveness. 

Individuals who have migraine or epilepsy, and also those with encephalitis, may experience a recurrence of AIWS symptoms when the disease is active.

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



An exception to pharmacotherapy for AIWS is antipsychotic medications, which are not considered useful. When distortions occur as a comorbid symptom in a patient with psychosis, it is important to know that these distortions can sometimes be triggered or exacerbated by antipsychotic medications.These medications can lower the threshold for epileptic activity.


What this means for you

AIWS is a rare disorder, but it may be more prevalent than previously thought. It should be considered in patients with migraine, for whom migraine treatment and prophylaxis may be beneficial. Although the characteristic AIWS disruptions in perception may appear as psychosis, research suggests that alterations in the brain’s perceptual networks may be at the root of AIWS. Thus, antipsychotics are of marginal use in patients with AIWS, and they can lower the seizure threshold. 



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