Type A
Body schema disorder: Partial or whole-body macrosomatognosia/microsomatognosia.
Associated symptoms: May include derealization, depersonalization, and psychophysical duality.
Alice in Wonderland Syndrome
Key points at a glance
Section titled “Key points at a glance”1. What is Alice in Wonderland Syndrome?
Section titled “1. What is Alice in Wonderland Syndrome?”Alice in Wonderland Syndrome (AIWS) is a neurological syndrome primarily involving visual perception disturbances. It is characterized by distortions of body image, size perception, and time perception. It was first described in the medical literature by Lippman in 1952. In 1955, John Todd named it after the perceptual alterations experienced by characters in Lewis Carroll’s “Alice’s Adventures in Wonderland.”
Large-scale epidemiological data have not been published, and the exact prevalence is unknown. It is most commonly reported in children and young adults. A systematic review of 168 cases of time distortion showed a male-to-female ratio of 1.7:1, with a mean age of 31 years for women and 36 years for men (range 6–68 years)1). The prevalence in adult migraine patients is reported to be approximately 15–16.5%5).
Q
How common is AIWS?
A
Although large-scale epidemiological data are lacking, the prevalence in adult migraine patients is reported to be approximately 15–16.5%5). It is more common in children and young adults; a survey of Japanese adolescents found micropsia and macropsia in 6.5% of boys and 7.3% of girls.
2. Main symptoms and clinical findings
Section titled “2. Main symptoms and clinical findings”Subjective symptoms
Section titled “Subjective symptoms”- Micropsia and teleopsia: The most common symptoms. Objects appear smaller or farther away.
- Macropsia: Objects appear larger than normal.
- Metamorphopsia: Visual distortion such as wavy lines or contours.
- Body image distortion: One’s own body feels larger (macrosomatognosia) or smaller (microsomatognosia). In an 8-year-old girl, visual hallucinations (zoopsia: animal hallucinations) were also reported4).
- Auditory abnormalities: Misperception of everyday sounds, distortion of pitch or timbre may occur4).
- Altered time perception: Time feels accelerated (tachysensia) or slowed. In a systematic review, the speed-change type was the most common, accounting for 51% of cases1).
- Derealization and depersonalization: May be accompanied by a sense of unreality about oneself or the environment.
Clinical Findings (Findings Confirmed by Physician Examination)
Section titled “Clinical Findings (Findings Confirmed by Physician Examination)”Neurological examination usually reveals no focal abnormalities. The symptom classification by Mastria (2016) (Types A/B/C) is widely used.
Type B
Size and distance perception disorders: macropsia, micropsia, pelopsia, and teleopsia. This is the most common type, accounting for about three-quarters of all cases3).
Porropsia: A phenomenon in which micropsia and teleopsia occur simultaneously for the same object.
Type C
Mixed type: Symptoms of type A and type B are combined.
This applies when both type A and type B symptoms are present.
A 69-year-old man with right occipital lobe infarction secondary to stroke presented with macropsia, micropsia, dyschromatopsia, and macrosomatognosia3). In another case with macropsia, enhanced stereopsis, focal impaired awareness seizures, and supraventricular tachycardia, EEG revealed rhythmic theta activity (4–5 Hz) over the right hemisphere6).
3. Causes and Risk Factors
Section titled “3. Causes and Risk Factors”The causes of AIWS are diverse. The following shows the classification and frequency of causes.
A systematic review of time distortion (168 cases) found psychiatric disorders 17%, migraine 14%, intoxication 14%, and epilepsy 10% in that order1).
| Classification | Main Causes |
|---|---|
| Central Nervous System Diseases | Migraine (most common), epilepsy, cerebrovascular disorders, tumors |
| Infectious diseases | EBV (second most common), H1N1, Coxsackie, cytomegalovirus, VZV |
| Medications | Topiramate, montelukast, dextromethorphan |
| Psychoactive substances | LSD, marijuana, cocaine |
| Mental illness | Schizophrenia, depression |
- Migraine: The most common cause, accounting for about 27.1% of all cases. Association with vestibular migraine has also been reported5).
- Epilepsy: About 3% of all cases. Association with right hemisphere lesions is suggested, and AIWS-like symptoms may appear as focal impaired awareness seizures6).
- Cerebrovascular disorders: Cases due to isolated cortical venous thrombosis of the right occipital lobe have been reported2). Cases associated with right posterior cerebral artery territory infarction have also been reported3).
- Drug-induced: Topiramate can induce AIWS. In a 40-year-old woman, macrosomatognosia appeared after increasing the dose to 100 mg/day and disappeared 5 days after discontinuation5) (see Standard treatment for details).
Q
Can AIWS be caused by medications?
A
Cases have been reported where medications for migraines and epilepsy, such as topiramate, triggered AIWS symptoms 5). In many cases, symptoms disappeared within days after discontinuing the medication. When new perceptual changes appear, the possibility of a drug-induced cause should be considered.
4. Diagnosis and Testing Methods
Section titled “4. Diagnosis and Testing Methods”Diagnosis is made clinically. The diagnostic criteria for migraine-associated AIWS (Valença 2015) are as follows.
- One or more episodes of autoscopic body schema illusion or metamorphopsia
- Duration less than 30 minutes
- Associated with headache or history of migraine
- MRI, cerebrospinal fluid analysis, and EEG are all normal (although VEP may show abnormalities)
- MRI/EEG: Necessary to exclude structural causes, but usually normal. T2*-weighted MRI is useful for detecting cortical venous thrombosis in the right occipital lobe, which may be missed on CT 2).
- EEG: In epilepsy-related AIWS, rhythmic theta activity (4–5 Hz) in the right cerebral hemisphere may be detected 6). In focal status epilepticus, persistent 1–2 Hz sharp waves were observed in the right centrotemporal region 3).
- Diagnosis in children: There are no established diagnostic criteria, and it may be difficult for children to verbalize symptoms. The fact that the patient recognizes the hallucinations as not real is useful for differentiating from psychosis 4).
- Differential diagnosis: Psychosis (hallucinations), epilepsy, visual snow syndrome.
5. Standard Treatment
Section titled “5. Standard Treatment”No specific treatment for AIWS has been established. Most cases resolve spontaneously, and treatment of the underlying condition is the principle.
- Self-limited course: AIWS often resolves spontaneously over time.
- Migraine prophylaxis therapy: Anticonvulsants, beta-blockers, calcium channel blockers, and antidepressants are used. A low-tyramine diet may also be used concurrently 4).
- Epilepsy-related AIWS: In one case, levetiracetam (2,000 mg/day) resolved AIWS-like symptoms, focal seizures, and tachycardia within 4 weeks 6). Another report described resolution of status epilepticus and AIWS symptoms with phenytoin (1,200 mg loading dose followed by 100 mg three times daily maintenance) 3). A case treated with lacosamide remained recurrence-free for one year 2).
- Management of drug-induced AIWS: Discontinuation of the causative drug is effective. In one case, symptoms resolved within 5 days after stopping topiramate 25 mg/day for 3 days 5). Previous reports also indicate resolution within 4–23 days after discontinuation 5).
- Antipsychotics: Their efficacy is limited, and given the neurological origin of AIWS, they are not first-line treatment 4).
Q
Is there a specific treatment for AIWS?
A
No specific treatment for AIWS has been established. Since many cases resolve spontaneously, appropriate treatment of the underlying condition (migraine, epilepsy, infection, etc.) is the top priority. In epilepsy-related cases, there are reports that seizure management with antiepileptic drugs also led to the disappearance of AIWS symptoms 6).
6. Pathophysiology and Detailed Mechanisms
Section titled “6. Pathophysiology and Detailed Mechanisms”The temporo-parieto-occipital (TPO) junction is where visual and somatosensory information are integrated, generating internal and external representations of the self. Dysfunction in this area is thought to underlie AIWS symptoms.
- Right hemisphere dominance: In studies of lesion localization, right hemisphere lesions accounted for 63%, left hemisphere 23%, and bilateral 10% 1). Visual type (type B) is associated with right hemisphere visual pathway damage, while somatosensory types (type A/C) are more diffuse but consistently localized to the right side 3).
- Role of the right occipital lobe (BA 18/19): In two cases of cortical venous thrombosis, lesions were confirmed in the right occipital lobe BA 18 and 19 2). The fusiform gyrus BA 19 is involved in integrative visual processing, and size constancy perception and discrimination involve the prestriate cortex and inferotemporal regions 2).
- Hypoperfusion of the nondominant parietal lobe: Symptoms are thought to arise from reduced blood flow to the nondominant parietal lobe during a migraine attack.
- Hyperconnectivity hypothesis: Hyperconnectivity between V3 and the posterior superior temporal sulcus has been reported in migraine patients with AIWS, which is not observed in typical migraine aura or healthy individuals5).
- Desynchronization hypothesis: Time perception involves distributed networks, and temporal mismatch (desynchronization) between sensory modalities can cause time distortion1). The occipital cortex was most prominent in localization data for time distortion, with 53% on the right and 57% on the left1).
- Epileptic mechanism: Epileptic discharges in the right occipital and temporal lobes can cause AIWS. Cases where AIWS symptoms disappeared after improved seizure control suggest that epilepsy is an exacerbating factor3).
- Autonomic involvement: In AIWS associated with focal epilepsy, paroxysmal sinus tachycardia occurred concurrently. Right hemisphere epileptic foci are associated with sympathetic-dominant autonomic changes6).
Q
Why does AIWS occur more easily with right hemisphere lesions?
A
In lesion localization data for AIWS, right hemisphere lesions account for 63%, the highest proportion 1), and the visual type (type B) is strongly associated with damage to the right hemisphere visual pathway 3). The right hemisphere’s dominance in spatial processing and body schema integration is considered the basis for the right-sided predominance of AIWS.
7. Latest Research and Future Perspectives (Research-Stage Reports)
Section titled “7. Latest Research and Future Perspectives (Research-Stage Reports)”- Drug-induced AIWS: The association between topiramate and AIWS has been assessed as “possible” on the Naranjo ADR Probability Scale 5), and the clinical importance of the possibility that migraine and epilepsy medications may themselves induce AIWS is being recognized.
- Lesion mapping studies: The lesion mapping study by Piervincenzi et al. (2022) has contributed to elucidating the responsible lesions in AIWS, as mentioned in multiple case reports2)3).
- Association between epilepsia partialis continua (EPC) and AIWS: The co-occurrence of EPC and AIWS has not been previously reported and is noted as a new finding suggesting localization of the epileptic focus in the right hemisphere3).
- Development of standardized diagnostic criteria in children: Establishing standardized criteria for accurate diagnosis of pediatric AIWS is considered a future challenge4).
- Classification system for time distortion: Blom et al. proposed a system classifying time distortion into five types1), advancing systematic understanding of time perception abnormalities that had previously received little attention.
8. References
Section titled “8. References”- Blom JD, Nanuashvili N, Waters F. Time Distortions: A Systematic Review of Cases Characteristic of Alice in Wonderland Syndrome. Front Psychiatry. 2021;12:668633.
- Kobayashi Y, Tazawa K, Mochizuki Y, Kondo Y, Yamamoto K, Sekijima Y. Two Cases of Alice in Wonderland Syndrome with a Right Occipital Lobe Lesion Caused by Isolated Cortical Venous Thrombosis. Intern Med. 2024;63:2083-2087.
- Mbizvo GK, Bharambe V, Hywel B, Biswas S, Larner AJ. Alice in Wonderland Syndrome: Localising insights from right visual cortex stroke complicated by epilepsia partialis continua. Epilepsy Behav Rep. 2025;29:100745.
- Manwar S, Sapkale B, Patil T, Vagga A. A Twist in Perception: A Case of an Eight-Year-Old Female With Alice in Wonderland Syndrome. Cureus. 2024;16(5):e60182.
- Jiang WX, Leung JG, Carlson DN, Staab JP. A case of Alice in Wonderland Syndrome associated with topiramate in a patient with vestibular migraine. Ment Health Clin. 2025;15(4):208-13.
- Panpruang P, Wongwandee M, Rattanajaruskul N, Roongsangmanoon W, Wongsoasu A, Angkananard T. Alice in Wonderland Syndrome-Like Seizure and Refractory Supraventricular Tachycardia. Case Rep Neurol. 2021;13:716-723.