Down the Rabbit Hole We Go: Alice in Wonderland Syndrome

“It was much pleasanter at home,” thought poor Alice, “when one wasn’t always growing larger and smaller, and being ordered about by mice and rabbits.”

 – Alice in Wonderland, Lewis Carrol

Imagine sitting at your desk, and within seconds, your hands balloon to the size of a couch, the doorway across the room recedes into an infinite tunnel, and the ticking clock on the wall sounds like it is dragging through molasses. No, you are not mad, and this is not a trip down a rabbit hole; it is a real neurological phenomenon known as Alice in Wonderland Syndrome (AIWS), or Todd’s syndrome (Figure 1) (Weissenstein et al. 2014)

First named by British psychiatrist John Todd in 1955, AIWS is a disorienting neuropsychiatric disorder characterized by transient, reversible distortions in visual perception, body schema, and the subjective passage of time (Weissenstein et al. 2014). AIWS frequently manifests as a severe variant of a migraine aura, an epileptic seizure, or a neurological response to acute viral infections (Blom 2016). Clinicians typically diagnose AIWS by exclusion, utilizing MRIs and EEGs to rule out structural lesions or focal ischemia before treating the underlying trigger, such as migraine prophylaxis or managing seizure activity (Brumm et al. 2010).

To capture what actually happens inside the brain during these bizarre events, researchers have utilized advanced neuroimaging. In a notable fMRI case study of a 12-year-old boy experiencing a viral-onset episode of micropsia (where objects visually shrink), scientists observed aberrant blood-oxygen-level-dependent activity directly within the primary and extrastriate visual cortices, alongside increased activation in the parietal lobe (Brumm et al. 2010). This study proved that these distortions stem from real, transient functional disruptions in how the brain processes space and scale (Figure 2).

Simultaneously, the psychological and cognitive sciences provide a vital lens for understanding how patients navigate these distortions while maintaining full wakeful consciousness. Individuals realize that what they are seeing or feeling does not match objective reality, which frequently induces sudden panic or anxiety. Medical literature categorizes these disruptions into metamorphopsias (such as macropsia and micropsia), somatognosic disturbances, and chronometric alterations. Because patients remain lucid, psychological support and cognitive validation are essential to help them cope with the dissociative feelings of depersonalization and derealization (Fine et al. 2017).

Maybe Lewis Carrol was onto something, maybe he was a bit mad himself. 

References:

Blom, Jan Dirk. 2016. “Alice in Wonderland Syndrome: A Systematic Review.” Neurology Clinical Practice 6 (3): 259–70. https://doi.org/10.1212/CPJ.0000000000000251.

Brumm, Kathleen, Matthew Walenski, Frank Haist, Shira L. Robbins, David B. Granet, and Tracy Love. 2010. “Functional MRI of a Child with Alice in Wonderland Syndrome during an Episode of Micropsia.” Journal of AAPOS : The Official Publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus 14 (4): 317–22. https://doi.org/10.1016/j.jaapos.2010.03.007.

Carroll, Lewis, and Donald J. Gray. 2013. Alice in Wonderland. Third edition. A Norton Critical Edition. W. W. Norton & Company.

Fine, Edward, Osman Farooq, and Naimeen Mahfooz. 2017. “Alice In Wonderland Syndrome: A History (P2.042).” Neurology 88 (16_supplement): P2.042. https://doi.org/10.1212/WNL.88.16_supplement.P2.042.

Weissenstein, Anne, Elisabeth Luchter, and Ma Stefan Bittmann. 2014. “Alice in Wonderland Syndrome: A Rare Neurological Manifestation with Microscopy in a 6-Year-Old Child.” Journal of Pediatric Neurosciences 9 (3): 303. https://doi.org/10.4103/1817-1745.147612.