Alice In Wonderland Syndrome
“Well! I’ve often seen a cat without a grin,” thought Alice, “but a grin without a cat! It’s the most curious thing I ever saw in all my life!”
From ‘Alice’s Adventures in Wonderland’ by Lewis Carroll.
Curiouser and Curiouser
Alice in wonderland is unarguably one of the most unique, ecstatic, and eccentric books one has ever read. It duly satisfies childhood imagination interspersed with humorous philosophical questions, witty poetry, and somewhat peculiar sarcasm. One can’t help but wonder if its author, Charles Lutwidge Dodgson, known by his pseudonym Lewis Carroll, was high on drugs while writing this masterpiece. After all, this was the era of legal opium use. Charles Dodgson, a mathematician at Christ Church, Oxford, first told this bizarre story to dean Henry Liddell's daughters as they rowed down the Thames. After the boating trip, 10-year-old Alice Liddell badgered Dodgson to write it down, and Alice in Wonderland — under the nom de plume Lewis Carroll — was born.
Accentuated by John Tenniel's illustrations, the book effectively depicts a young innocuous child’s dreamy fantasies and innocent, silly thoughts. But was that all merely a dream. Or was Carroll trying to underline some shady subtleties? Silhouettes of mental illness do pass one’s mind on second thoughts, but surely this can never happen in real life, right?
In 1950, a case study listed a man claiming that his head was twice as big and as light as a feather, and occasionally, his limbs went missing. A woman reported that she got so big that if she put out her hand, she could touch the far wall, and suddenly, it would drop off and disappear. Similar reports encompassing all kinds of Alice-esque experiences began to crop up, ranging from people looking distorted to crooked windows and TV hanging upside down. Finally, in 1955, Dr. John Todd named this condition, rather succinctly, as the ‘Alice In Wonderland Syndrome’(AIWS). Also referred to as ‘Todd’s Syndrome’ or ‘Lilliputian hallucinations,’ the etymology couldn’t get any clearer.
Today, some 55 different types of perceptual distortion are known that may occur in the context of AIWS.
Some of the perceptual distortions are as follows:
Pelopsia- a feeling that objects near one are growing larger or closer to one than they really are.
Teleopsia- a sensation that objects are getting smaller or farther away than they really are.
(Just like looking through a telescope or looking through the wrong end of a telescope.)
Metamorphopsia- visual distortion of size, color, and movement.
Zoopsia- involves 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.)
Macro and micro somatognosia- rare disorders of the body's cerebral representation whereby patients perceive body parts as disproportionately large (when Alice eats the cake) and small (when Alice drinks from a bottle expertly labeled ‘Drink Me’) respectively.
Micropsia and macropsia- making objects in one’s surroundings, compared to normal, look exceedingly minute and inordinately humongous, respectively.
Entemopia- often described as looking at the world through a bug’s eye view.
Along with these interesting and at times conceptually overlapping visual distortions, auditory hallucinations like distorted hearing, unexplained noises are also included in AIWS.
Then one may ask, what is the difference between the hallucinations experienced in Schizophrenia or after drug use and the ones experienced in AIWS. First things first, the chief difference is that AIWS mostly concerns distortions rather than illusions or hallucinations. Also, people with AIWS always seem to know and recognize that what they are perceiving is some sort of distortion. Illusions have a source in the outside world that is misinterpreted by the brain, while hallucinations are sensations that appear to be real but are created within the mind. Distortions, instead, are percepts experienced by a waking individual, which are based on appropriate stimuli from the outside world, of which a highly specific aspect is altered in a consistent manner.
Another interesting condition in AIWS is the distorted perception of time. For some, time may pass exceedingly slow, almost freezing in some frames known as protracted duration, while for some, it may pass at a lightning-fast pace known as the quick motion phenomenon. The incidence of AIWS can differ widely- the general range is anywhere between 10 seconds and 10 minutes.
Distorted perceptions are most common in kids. The mean age of AIWS ranges 6 years (Alice was 7 years old in ‘Alice’s Adventures In Wonderland,’ and 7.5 years old in the sequel ‘Through the Looking-Glass and What Alice Found There’), but it is very normal for some patients to experience the syndrome from childhood up to their late 20s. Some studies found 65% of cases of AIWS are reported in children under 18 years of age, while some reported 78%. The exact statistics of AIWS incidence vary because of the condition being so rare. In the literature, no more than 180 “clinical” cases of AIWS have been described (i.e., cases in need of medical attention). One cannot ignore the large number of cases that could be misinterpreted or remaining dormant and never been reported. Are the exact causes of AIWS known yet?
Supposed Causes of AIWS
Case studies reveal the emergence of infections such as the Epstein–Barr (EB) virus, medications such as topiramate (used in the treatment of seizures, migraines, bipolar disorder, and weight loss), associated migraine disorders in addition to familial inheritance to be the supposed causes of AIWS.
In the 1950s, cases of AIWS were mainly reported in people who had migraines or epilepsy or people with a family history of migraine or epilepsy. 15% of people having AIWS have migraines. Sensory disturbances called ‘aura’ precede headaches in migraines where minor visual disturbances like flashes of light or zigzag lines are reported. But a clear link hasn’t been uncovered yet because this is not always the case. Most of the time, AIWS exists as a side effect of infection. For example, the Epstein-Barr (EB) virus causes a condition known as infectious mononucleosis (colloquially referred to as ‘mono’). EBV causes an infection that affects the blood flow to the brain's sensory regions, in turn affecting processivity. A 1998 study consisted of 4 kids having AIWS, in which 3 of them had a recent respiratory infection, and 2 of them had the EB virus. However, all 4 had a common trend-decreased blood flow to at least some brain region. The respective areas affected differed; however, all of the affected areas were localized somewhere near the brain’s visual part. Areas which if affected in some manner, created hallucinations on extrinsic stimulations. Now, one may say that the sample size is too small to make any generalization but do remember that AIWS is a rare neurological disorder, so any and every observation at this stage can prove to be fruitful.
In another study concerning 166 individuals suffering from AIWS, 22.9% suffered from infectious diseases, and 21.7% were under 18 years of age. In 2010, a rather strange incident took place. A boy experienced AIWS while in an MRI machine. This pinpointed the exact regions related to AIWS onset in that particular case. More parietal lobe activation and less visual center activation were observed during AIWS while performing spatial reasoning tasks that test the parietal lobe’s visual pathway (tells us where things are located in space or proprioception). Various neuroimaging studies have elucidated a network of brain regions associated with AIWS. These include the temporoparietal region within the parietal lobe and the visual pathway, including the occipital lobe. Thus overall, the temporoparietal junction and temporal, occipital, and parietal lobes seem to be involved in AIWS incidence. Head trauma or brain tumor can also be a likely cause. However, in about half of the cases, the reasons involved are unknown.
Treatment for AIWS
Currently, there is no direct treatment for AIWS. There are treatments only for comorbid and associated disorders. Future research is needed to elucidate the genetic, environmental, and pathophysiological causes associated with AIWS, leading to more specific or direct treatments and possibly a cure for AIWS. The symptoms usually fade with time in kids as cortical excitations decrease and visual perceptions mature in the visual cortex’s ventral pathway with increasing age. But in one-third of the cases, symptoms can persist, sometimes worsening and developing into neurodegenerative disorders like dementia, as was reported in one of the cases of an elderly patient.
AIWS can be characterized by perceptual misattributions or distortions rather than a psychiatric illness. The rareness of the condition does make it difficult to define its essence stringently. Diagnostic and Statistical Manual of mental disorders- 5th edition or DSM5 doesn’t list AIWS as a diagnostic criterion. In contrast, the American Psychiatric Association and International Classification of diseases do pay special attention to it.
Conclusion
Lewis Carroll himself suffered from migraines, according to accounts from his diaries. So, it has been speculated by some that he himself suffered from AIWS. From the mystical world of the rabbit in a waistcoat, unbirthday presents, a hookah-smoking caterpillar, the Red Queen who wants everyone’s head off, the Mad Hatter and the Cheshire Cat, one could, at first glance, never infer such conclusions but in the undertone of it all, lie AIWS and other speculated conditions like erethism or mercury poisoning (in the Mad Hatter’s case) and narcissistic personality disorder (in the case of the Red Queen). But howsoever one might interpret it, Alice In Wonderland was written primarily to entertain, and it continues to remain an enrapturing lucid dream filled with the sweet petrichor of inspired fantasy.
“In that direction,” the Cat said, waving its right paw round, “lives a Hatter: and in that direction,” waving the other paw, “lives a March Hare. Visit either you like: they’re both mad.” “But I don’t want to go among mad people,” Alice remarked. “Oh, you ca’n’t help that,” said the Cat: “we’re all mad here. I’m mad. You’re mad.”
From ‘Alice’s Adventures in Wonderland’ by Lewis Carroll.
