alice in wonderland syndrome alice in wonderland syndrome alice in wonderland syndrome (aiws), also known as todd's syndrome or dysmetropsia, is a neuropsychological condition that causes a distortion of perception. people may experience distortions in visual perception of objects, such as appearing smaller (micropsia) or larger (macropsia), or appearing to be closer (pelopsia) or farther (teleopsia) than they are. distortion may also occur for senses other than vision. alice in wonderland syndromeother namestodd's syndrome, lilliputian hallucinations, dysmetropsiathe perception a person can have due to micropsia, a potential symptom of dysmetropsia. from lewis carroll's 1865 novel alice's adventures in wonderlandspecialtypsychiatry, neurologysymptoms macropsia - objects are perceived larger than their actual size micropsia - objects are perceived smaller than their actual size pelopsia - objects are perceived nearer than they actually are teleopsia - objects are perceived much further away than they are metamorphopsia - altered perception of shape impaired time perception complicationsimpaired visionusual onsetbefore, during, or after a migrainedurationeach symptom is separate and will only occur for a 20-to-50-minute period. the cause of alice in wonderland syndrome is currently unknown, but it has often been associated with migraines, head trauma, or viral encephalitis caused by epstein–barr virus infection. it is also theorized that it can be caused by abnormal amounts of electrical activity, resulting in abnormal blood flow in those parts of the brain which process visual perception and texture. although there are cases of alice in wonderland syndrome in both adolescents and adults, it is most commonly seen in children. classification though not agreed upon in literature, some authors classify only symptoms involving changes in perception of a person's body image as true alice in wonderland syndrome and instead use the term "alice in wonderland-like syndrome" to classify any symptoms involving other changes in perception of vision, time, hearing, touch or other extra-personnel perceptions. signs and symptoms with over 60 associated symptoms, alice in wonderland syndrome affects the sense of vision, sensation, touch, and hearing, as well as the perception of one's body image. migraines, nausea, dizziness, and agitation are also commonly associated symptoms with alice in wonderland syndrome. less frequent symptoms also include loss of limb control and coordination, memory loss, lingering touch and sound sensations, and emotional instability. alice in wonderland syndrome is often associated with distortion of sensory perception, which involves visual, somatosensory, and non-visual symptoms. alice in wonderland syndrome is characterized by the individual being able to recognize the distortion in the perception of their own body and is episodic. alice in wonderland syndrome episodes varies in length from person to person. episodes typically last from a few minutes to an hour, and each episode may vary in experience. visual distortions individuals with alice in wonderland syndrome can experience illusions of expansion, reduction, or distortion of their body image, such as microsomatognosia (feeling that their own body or body parts are shrinking), or macrosomatognosia (feeling that their body or body parts are growing taller or larger). these changes in perception are collectively known as metamorphopsias, or lilliputian hallucinations, which refer to objects appearing either smaller or larger than reality. people with certain neurological diseases may also experience similar visual hallucinations. within the category of lilliputian hallucinations, people may experience either micropsia or macropsia. micropsia is an abnormal visual condition, usually occurring in the context of visual hallucination, in which the affected person sees objects as being smaller than they are in reality. macropsia is a condition where the individual sees everything larger than it is. these visual distortions are sometimes classified as "alice in wonderland-like syndrome" instead of true alice in wonderland syndrome but are often still classified as alice in wonderland syndrome by health professionals and researchers since the distinction is not official. it was reported, by lanska and lanska (2013), that of all clinical cases, "some 85% of patients present with perceptual distortions in a single sensory modality, e.g., only visual or only somesthetic. moreover, the majority experience only a single type of distortion, e.g., only micropsia or only macropsia." hallucinations zoopsia is an additional hallucination that is sometimes associated with alice in wonderland syndrome. zoopsias involve hallucinations of either swarm of small animals (e.g. ants and mice, etc.), or isolated groups of larger animals (e.g. dogs and elephants, etc.). this experience of zoopsias is a shared symptom of a variety of conditions, such as delirium tremens. in addition, some people may, in conjunction with a high fever, experience more intense and overt hallucinations, seeing things that are not there, and misinterpreting events and situations. depersonalization/derealization along with these size, mass, and shape distortions of the body, those with alice in wonderland syndrome often experience a feeling of disconnection from one's own body, feelings, thoughts, and environment. hearing and time distortions individuals experiencing alice in wonderland syndrome can also often experience paranoia as a result of disturbances in sound perception. these disturbances can include the amplification of soft sounds or the misinterpretation of common sounds. other auditory changes include distortion in pitch and tone and hearing indistinguishable and strange voices, noises, or music. a person affected by alice in wonderland syndrome may also lose a sense of time, a problem similar to the lack of spatial perspective brought on by visual distortion. time may seem to pass very slowly, similar to an lsd experience, and the lack of time and space perspective can also lead to a distorted sense of velocity. for example, an object could be moving extremely slowly in reality, but to a person experiencing time distortions, it could seem that the object was sprinting uncontrollably along a moving walkway, leading to severe, overwhelming disorientation. having symptoms of time distortion is correlated with various underlying conditions, for example, substance use, migraine, epilepsy, head trauma, and encephalitis. regardless of an individual's disease diagnosis, time distortions are often included as a symptom associated with alice in wonderland syndrome since they are classified as perceptual distortions. therefore, a person can be described as having alice in wonderland syndrome even if that person is experiencing time distortions due to an underlying condition. causes because alice in wonderland syndrome is not commonly diagnosed and documented, it is difficult to estimate what the main causes are, if there are any. the cause of over half of the documented cases of alice in wonderland syndrome is unknown. complete and partial forms of the alice in wonderland syndrome exist in a range of other disorders, including epilepsy, intoxicants, infectious states, fevers, and brain lesions. furthermore, the syndrome is commonly associated with migraines, as well as the use of psychoactive drugs. it can also be the initial symptom of the epstein–barr virus (see mononucleosis), and a relationship between the syndrome and mononucleosis has been suggested. within this suggested relationship, epstein–barr virus appears to be the most common cause in children, while for adults it is more commonly associated with migraines. infectious diseases a 2021 review found that infectious diseases are the most common cause of alice in wonderland syndrome, especially in pediatrics. some of these infectious agents included epstein–barr virus, varicella zoster virus, influenza, zika, coxsackievirus, plasmodium falciparum protozoa, and mycoplasma pneumoniae/streptococcus pyogenes bacteria. association of alice in wonderland syndrome is most commonly seen with epstein-barr virus. however, pathogenesis is not well understood beyond these reviews. in some instances, alice in wonderland syndrome was reported to be associated with an influenza a infection and it is possible that there may be other unreviewed causes as well. cerebral hypotheses alice in wonderland syndrome can be caused by abnormal amounts of electrical activity resulting in abnormal blood flow in the parts of the brain that process visual perception and texture. nuclear medical techniques using technetium, performed on individuals during episodes of alice in wonderland syndrome, have demonstrated that alice in wonderland syndrome is associated with reduced cerebral perfusion in various cortical regions (frontal, parietal, temporal and occipital), both in combination and in isolation. one hypothesis is that any condition resulting in a decrease in perfusion of the visual pathways or visual control centers of the brain may be responsible for the syndrome. for example, one study used single photon emission computed tomography to demonstrate reduced cerebral perfusion in the temporal lobe in people with alice in wonderland syndrome. other theories suggest the syndrome is a result of non-specific cortical dysfunction (e.g. from encephalitis, epilepsy, decreased cerebral blood flow), or reduced blood flow to other areas of the brain. other theories suggest that distorted body image perceptions stem from within the parietal lobe. this has been demonstrated by the production of body image disturbances through electrical stimulation of the posterior parietal cortex. other researchers suggest that metamorphopsias, or visual distortions, may be a result of reduced perfusion of the non-dominant posterior parietal lobe during migraine episodes. throughout all the neuroimaging studies, several cortical regions (including the temporoparietal junction within the parietal lobe, and the visual pathway, specifically the occipital lobe) are associated with the development of alice in wonderland syndrome symptoms. migraines the role of migraines in alice in wonderland syndrome is still not understood, but both vascular and electrical theories have been suggested. for example, visual distortions may be a result of transient, localized ischemia in areas of the visual pathway during migraine attacks. in addition, a spreading wave of depolarization of cells (particularly glial cells) in the cerebral cortex during migraine attacks can eventually activate the trigeminal nerve's regulation of the vascular system. the intense cranial pain during migraines is due to the connection of the trigeminal nerve with the thalamus and thalamic projections onto the sensory cortex. alice in wonderland syndrome symptoms can precede, accompany, or replace the typical migraine symptoms. typical migraines (aura, visual derangements, hemicrania headache, nausea, and vomiting) are both a cause and an associated symptom of alice in wonderland syndrome. alice in wonderland syndrome is associated with macrosomatognosia which can mostly be experienced during migraine auras. genetic and environmental influence while there currently is no identified genetic locus/loci associated with alice in wonderland syndrome, observations suggest that a genetic component may exist but the evidence so far is inconclusive. there is also an established genetic component for migraines which may be considered to be a possible cause and influence for hereditary alice in wonderland syndrome. though most frequently described in children and adolescents, observational studies have found that many parents of children experiencing alice in wonderland syndrome have also experienced similar symptoms themselves, though often unrecognized. family history may then be a potential risk factor for alice in wonderland syndrome. one example of environmental influences on the incidence of alice in wonderland syndrome includes the drug use and toxicity of topiramate. other reports of tyramine usage and the association with alice in wonderland syndrome has been reported but current evidence is inconclusive. further research is required to establish the genetic and environmental influences on alice in wonderland syndrome. the neuronal effect of cortical spreading depression (csd) on tpo-c may demonstrate the link between migraines and alice in wonderland syndrome. as children experience alice in wonderland syndrome more than adults, it is hypothesized that structural differences in the brain between children and adults may play a role in the development of this syndrome. diagnosis alice in wonderland syndrome is not part of any major classifications like the icd-10 and the dsm-5. since there are no established diagnostic criteria for alice in wonderland syndrome, and because alice in wonderland syndrome is a disturbance of perception rather than a specific physiological condition, there is likely to be a large degree of variability in the diagnostic process and thus it can be poorly diagnosed. often, the diagnosis can be presumed when other causes have been ruled out. additionally, alice in wonderland syndrome can be presumed if the patient presents symptoms along with migraines and complains of onset during the day (although it can also occur at night). ideally, a definite diagnosis requires a thorough physical examination, proper history taking of episodes and occurrences, and a concrete understanding of the signs and symptoms of alice in wonderland syndrome for differential diagnosis. a person experiencing alice in wonderland syndrome may be reluctant to describe their symptoms out of fear of being labeled with a psychiatric disorder, which can contribute to the difficulty in diagnosing alice in wonderland syndrome. in addition, younger individuals may struggle to describe their unusual symptoms, and thus,