Hallucinations and illusions in migraine in children and the Alice in Wonderland Syndrome

Brain circuits in autonomous sensory meridian response and related phenomena

Autonomous sensory meridian response (ASMR) is characterized by a tingling sensation with a feeling of relaxation and a state of flow. We explore the neural underpinnings and comorbidities of ASMR and related phenomena with altered sensory processing. These phenomena include sensory processing sensitivity (SPS), synaesthesia, Alice in Wonderland syndrome and misophonia. The objective of this article is to uncover the shared neural substrates and distinctive features of ASMR and its counterparts. ASMR, SPS and misophonia exhibit common activations in the brain regions associated with social cognition, emotion regulation and empathy. Nevertheless, ASMR responders display reduced connectivity in the salience network (SN), while individuals with SPS exhibit increased connectivity in the SN. Furthermore, ASMR induces relaxation and temporarily reduces symptoms of depression, in contrast to SPS and misophonia, which are linked to depression. These observations lead us to propose that ASMR is a distinct phenomenon owing to its attention dispatch mechanism and its connection with emotion regulation. We suggest that increased activations in the insula, along with reduction in connectivity within the salience and default mode networks in ASMR responders, may account for their experiences of relaxation and flow states. This article is part of the theme issue 'Sensing and feeling: an integrative approach to sensory processing and emotional experience'.

A Narrative Review of Visual Hallucinations in Migraine and Epilepsy: Similarities and Differences in Children and Adolescents

Since the earliest descriptions of the simple visual hallucinations in migraine patients and in subjects suffering from occipital lobe epilepsy, several important issues have arisen in recognizing epileptic seizures of the occipital lobe, which often present with symptoms mimicking migraine. A detailed quantitative and qualitative clinical scrutiny of timing and characteristics of visual impairment can contribute to avoiding mistakes. Differential diagnosis, in children, might be challenging because of the partial clinical, therapeutic, and pathophysiological overlaps between the two diseases that often coexist. Ictal elementary visual hallucinations are defined by color, shape, size, location, movement, speed of appearance and duration, frequency, and associated symptoms and their progression. The evaluation of the distinctive clinical features of visual aura in migraine and visual hallucinations in occipital epilepsy could contribute to understanding the pathogenetic mechanisms of these two conditions. This paper aims to critically review the available scientific evidence on the main clinical criteria that address diagnosis, as well as similarities and differences in the pathophysiological mechanisms underlying the visual impairment in epilepsy and migraine.

Visual Disturbances Spectrum in Pediatric Migraine

Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.

Multisensory perceptual distortion including auditory distortions in Alice in Wonderland syndrome: a case report

Alice in Wonderland syndrome (AIWS) is a rare perceptual disorder characterized mainly by perceptual distortions of visual objects and one's own body. While there are many case reports of visual and somatosensory distortions associated with AIWS, little is known about auditory distortion. Therefore, we present the case of a 22-year-old right-handed woman who described having auditory as well as visual and somatosensory distortion experiences and a family history of AIWS. The subject reported experiencing multisensory perceptual distortions, where she sees other people's faces as larger and hears their voices as louder at the same time. This particular case suggests that auditory distortion - which contributes to constructing the perception of the surrounding space and the body - may also be characterized as a perceptual symptom of AIWS.

The childhood migraine syndrome

Migraine is a complex genetic brain disorder with an intricate pathogenesis and polymorphous clinical presentations, particularly in children. In this Perspective, we describe the different phenotypes of migraine in children, including conditions that have been referred to in the International Classification of Headache Disorders as "syndromes that may be related to migraine''. Evidence is presented for the integration of abdominal migraine, cyclical vomiting syndrome, benign paroxysmal vertigo, benign paroxysmal torticollis and infantile colic into the unified diagnosis of 'childhood migraine syndrome' on the basis of clinical and epidemiological characteristics, and shared inheritance. In our opinion, such integration will guide clinicians from specialities other than neurology to consider migraine in the assessment of children with these disorders, as well as stimulate research into the genetics, pathophysiology and clinical features of all disorders within the syndrome. A diagnosis of childhood migraine syndrome would also enable patients to benefit from inclusion in clinical trials of old and new migraine treatments, thus potentially increasing the number of treatment options available.

Time Distortions: A Systematic Review of Cases Characteristic of Alice in Wonderland Syndrome

Of the perceptual distortions characteristic of Alice in Wonderland syndrome, substantial alterations in the immediate experience of time are probably the least known and the most fascinating. We reviewed original case reports to examine the phenomenology and associated pathology of these time distortions in this syndrome. A systematic search in PubMed, Ovid Medline, and the historical literature yielded 59 publications that described 168 people experiencing time distortions, including 84 detailed individual case reports. We distinguished five different types of time distortion. The most common category comprises slow-motion and quick-motion phenomena. In 39% of all cases, time distortions were unimodal in nature, while in 61% there was additional involvement of the visual (49%), kinaesthetic (18%), and auditory modalities (14%). In all, 40% of all time distortions described were bimodal in nature and 19% trimodal, with 1% involving four modalities. Underlying neurological mechanisms are varied and may be triggered by intoxications, infectious diseases, metabolic disorders, CNS lesions, paroxysmal neurological disorders, and psychiatric disorders. Bizarre sensations of time alteration-such as time going backwards or moving in circles-were mostly associated with psychosis. Pathophysiologically, mainly occipital areas appear to be involved, although the temporal network is widely disseminated, with separate component timing mechanisms not always functioning synchronously, thus occasionally creating temporal mismatches within and across sensory modalities (desynchronization). Based on our findings, we propose a classification of time distortions and formulate implications for research and clinical practice.

Pediatric Migraine Phenomena and Variants: Don't Let Them Go Over Your Head

PURPOSE OF REVIEW

Primary care providers, general pediatric neurologists, and other related subspecialty providers require a clear understanding of pediatric migraine with typical aura and its variants.

RECENT FINDINGS

We highlight some of the genetic mutations known to contribute to specific types of migraine with aura, discuss the ophthalmologic phenomena of migraine and call attention to some of the earliest manifestations of migraine in children, many of which have correlates in adulthood. While the majority of headaches in children are migraine with or without aura or tension type, many migraine and aura variants exist. Early and accurate diagnosis of episodic syndromes associated with migraine, as defined by the 2018 ICHD-3 criteria, can help to reduce unnecessary imaging, referrals, cost and anxiety, thereby benefiting patients and their families.

Do You See What I See? A Case of Alice in Wonderland Syndrome With EEG Correlate

Alice in Wonderland syndrome is a disorienting perceptual disorder characterized by discrete episodes of bizarre visual illusions and spatial distortions which has been associated with numerous neurologic and psychiatric conditions. Little is known regarding the electrophysiologic correlates of the visual symptoms described in this syndrome. The authors report the unique case of an 8-year-old boy presenting with visual distortions consistent with Alice in Wonderland syndrome, and an electroencephalogram demonstrating bilateral temporo-occipital slowing which correlated with symptoms of micropsia, teleopsia, and dysmorphopsia. Identification of this clinical syndrome and its electroclinical features are important for establishing a proper diagnosis and subsequent reassurance or appropriate treatment directed toward the underlying etiology.

Temporal-occipital glioblastoma presenting with Alice in Wonderland Syndrome in a patient with a long-time history of migraine without aura

Alice in Wonderland Syndrome (AIWS) is a rare perceptual disorder characterized by an erroneous perception of the body or the surrounding space. AIWS may be caused by different pathologies, ranging from infections to migraine. We present the case of a 54-year-old man, with a long-time history of migraine without aura, diagnosed with AIWS due to a glioblastoma located in the left temporal-occipital junction. To date, this is the first case of AIWS caused by glioblastoma. This case suggests that to exclude aura-mimic phenomena, a careful diagnostic workup should always be performed even in patients with a long-time history of migraine.

Evidence for the Perception of Time Distortion During Episodes of Alice in Wonderland Syndrome

Alice in Wonderland syndrome (AIWS) is a rare perceptual disorder associated with sensation of one or several visual and/or auditory perceptual distortions including size of body parts, size of external objects, or passage of time (either speeding up or slowing down). Cause for AIWS is yet to be widely agreed, and the implications are widely varied. One of the research difficulties is the brevity of each episode, typically not exceeding few tens of minutes. This article presents a male adult in late 20s who has apparently experienced AIWS episodes since childhood, and infection has been ruled out. Reaction speed tests were conducted during and after AIWS episodes, across a span of 13 months. Statistically significant evidence is present for delayed response time during AIWS episodes when the patient claims to experience a sensation of time distortion: where events seem to move faster and people appear to speak quicker.

Assessing and managing hallucinations in children and adolescents

Hallucinations (erroneous percepts in the absence of identifiable stimuli) are a key feature of psychotic states, but they have long been known to present in children with non-psychotic psychiatric disorders. Recent epidemiological studies of child populations found surprisingly high rates (about 10%) of hallucinatory experiences. These hallucinatory phenomena are most likely to occur in the absence of psychiatric disorder and are usually simpler, less elaborate and less distressing than those observed in children with psychiatric disorders. This article details the clinical assessment of hallucinations in children and adolescents, taking into account developmental considerations and paediatric organic associations. It describes hallucinations in young people with psychoses (schizophrenia spectrum and mood disorders) and non-psychotic psychiatric disorders (emotional and behavioural disorders), and it addresses therapeutic aspects.

Alice in Wonderland Syndrome: A Historical and Medical Review

Alice in Wonderland syndrome is a disorienting neurological condition that affects human perception to the senses of vision, hearing, touch, sensation, and the phenomenon of time. Individuals affected with Alice in Wonderland syndrome can experience alterations in their perception of the size of objects or their own body parts, known as metamorphopsias. It is known to occur in conditions including migraine, epilepsy, and certain intoxicants and infectious diseases. The name refers to Lewis Carrol's well-known children's book Alice's Adventures in Wonderland, in which the title character experiences alterations of sensation in which she felt that her body had grown too tall or too small, or parts of her body were changing shape, size, or relationship to the rest of her body. The syndrome was described in 1952 by Caro Lippman, and given its name in 1955 by John Todd. The metamorphopsias characteristic of this condition are also sometimes referred to as Lilliputian hallucinations, a reference to the fictional island of Lilliput in the novel Gulliver's Travels, written by Jonathan Swift in 1726. As such, many literary and medical publications have roots in the description of this syndrome. The purpose of this review is to summarize the literary and historical significance of Alice in Wonderland syndrome, as well as to provide the reader with a medical overview of the condition.

Alice in Wonderland Syndrome: A real life version of Lewis Carroll's novel

Alice in Wonderland Syndrome was originally coined by Dr. John Todd in 1955. The syndrome is named after the sensations experienced by the character Alice in Lewis Carroll's novel Alice's Adventures in Wonderland. Alice in Wonderland Syndrome consists of metamorphopsia (seeing something in a distorted fashion), bizarre distortions of their body image, and bizarre perceptual distortions of form, size, movement or color. Additionally, patients with Alice in Wonderland Syndrome can experience auditory hallucinations and changes in their perception of time. Currently, there is no known specific cause of Alice in Wonderland Syndrome. However, theories point to infections such as the Epstein-Barr virus, medications such as topiramate and associated migraines. Neuroimaging studies have revealed brain regions involved with the manifestation of symptoms. These include the temporo-parietal junction within the temporal lobe and the visual pathway, specifically the occipital lobe. There are no current treatments for Alice in Wonderland Syndrome. Further research is needed to find better treatments for Alice in Wonderland Syndrome and to elucidate the exact cause or causes of Alice in Wonderland Syndrome.

[Hallucinations: Etiological analysis of children admitted to a pediatric emergency department]

Children's hallucinations pose the dual challenge of diagnosing a possible medical emergency and a possible psychiatric disorder.

PURPOSE

The main objective was to analyze the causes of such hallucinations in children presenting to a pediatric emergency department.

MATERIAL AND METHODS

We conducted a single-center, observational, retrospective study including all children aged less than 15 years experiencing hallucinations and admitted to our tertiary level pediatric emergency department between 1 January 2007 and 31 December 2015. The data collected were demographic; medical: previous medical or psychiatric history, current medications, associated clinical or psychiatric symptoms, type and character of hallucinations, length and recurrence of hallucinatory phenomena; and other biological, radiological and neurological explorations.

RESULTS

Sixty-eight patients were included (29 boys). The mean age was 9.1±3 years (range, 2-14 years and 10 months; median, 9.2 years). Admissions were seasonal with a bimodal distribution (a peak during springtime and another one during fall). Hallucinations were mainly visual (90%), acute (77%) and complex (63%). Visual hallucinations were associated with other types of hallucinations: auditory (n=17), somatosensory (n=7). Fifteen children had a psychiatric history and had already experienced hallucinatory phenomena (93%). Among 47 patients (69%), these hallucinations were associated with other symptoms: agitation (41%), headaches (28%), hyperthermia (21%) and negative symptoms of the schizophrenia spectrum (15%). On admission, 20 patients (29%) had one or more treatments under way (34 drugs, 41% known for hallucinogenic adverse effects). Neurological explorations were undertaken in half of the cases. Toxicological analysis prescribed in 19 children was positive in five cases (26%). Fifty-three percent of patients were hospitalized and 51 children received a specialized follow-up (by a neurologist and/or a psychiatrist). A nonpsychiatric origin of these hallucinations was diagnosed in 29 patients (43%): neurological causes (n=10), infectious diseases (n=10), intoxications (n=5) and a medication side effect (n=4).

CONCLUSION

Hallucinations with a suspected underlying psychiatric cause differed on several factors: chronic duration (p=0.02), an onset after 10 years of age (p=0.004), previous identical episodes (p=0.014) and a parental psychiatric history (p=0.036), auditory hallucinations (p=0.0009), absence of fever (p=0.005), headaches (p=0.036) and the presence of negative symptoms of the schizophrenic spectrum (p=0.02).

Alice in Wonderland Syndrome: A Clinical and Pathophysiological Review

Alice in Wonderland Syndrome (AIWS) is a perceptual disorder, principally involving visual and somesthetic integration, firstly reported by Todd, on the literary suggestion of the strange experiences described by Lewis Carroll in Alice in Wonderland books. Symptoms may comprise among others aschematia and dysmetropsia. This syndrome has many different etiologies; however EBV infection is the most common cause in children, while migraine affects more commonly adults. Many data support a strict relationship between migraine and AIWS, which could be considered in many patients as an aura or a migraine equivalent, particularly in children. Nevertheless, AIWS seems to have anatomical correlates. According to neuroimaging, temporoparietal-occipital carrefour (TPO-C) is a key region for developing many of AIWS symptoms. The final part of this review aims to find the relationship between AIWS symptoms, presenting a pathophysiological model. In brief, AIWS symptoms depend on an alteration of TPO-C where visual-spatial and somatosensory information are integrated. Alterations in these brain regions may cause the cooccurrence of dysmetropsia and disorders of body schema. In our opinion, the association of other symptoms reported in literature could vary depending on different etiologies and the lack of clear diagnostic criteria.

Alice in Wonderland syndrome: A systematic review

Purpose of review:

To summarize the literature on Alice in Wonderland syndrome (AIWS), a disorder characterized by distortions of visual perception, the body schema, and the experience of time.

Recent findings:

On the basis of 169 published case descriptions, the etiology of AIWS is divided into 8 main groups, with neurologic disorders affecting mostly adults and elderly patients and encephalitides affecting mostly patients aged ≤18 years. Symptoms of AIWS are also experienced in the general population, with up to 30% of adolescents reporting nonclinical symptoms.

Summary:

In clinical cases of AIWS, auxiliary investigations (including blood tests, EEG, and brain MRI) are strongly advised. Treatment should be directed at the suspected underlying condition, although reassurance that the symptoms themselves are not harmful seems to suffice in about 50% of the cases. International classifications such as the DSM and ICD should consider placing the syndrome on their research agenda.

Migrainous Aura, Visual Snow, and "Alice in Wonderland" Syndrome in Childhood

Migraine is a condition that is common in the pediatric and adolescent population. Among children with migraine, visual aura can consist of either negative or positive features or both. Reports of sensory auras can also be elicited with a careful history. The understanding of the types of aura, as well as their relation to the more typical features of migraine, are discussed. The similar phenomena of visual snow and Alice in Wonderland syndrome in children are also described in detail.

Spectrum of migraine variants and beyond: The individual syndromes in children

"Migraine-related conditions" are probably the second most common condition after seizure encountered in pediatric neurology requiring frequent Emergency Department visits. Among migraines, migraine-related condition presents with an acute onset sign or symptom other than headache or visual aura of unknown etiology. A delay in diagnosis is a common occurrence. Previously, the authors proposed a common clinical profile and suggested that the future review should seek the applicability of the common profile in aid to clinical diagnosis of migraine-related individual syndromes. Authors describe the clinical characteristics and differential diagnosis of the spectrum of migraine variants and beyond in children.

Fifteen minute consultation on children 'hearing voices': when to worry and when to refer

Auditory hallucinations are uncommon paediatric presentations, but they can be alarming and lead to emergency consultations. This review outlines the phenomenology of auditory hallucinations, their assessment and clinical significance. Auditory hallucinations are seen in the course of acute medical disorders, often together with decreased levels of consciousness, as in febrile illness and in toxic, neurologically compromised states; they can also be a feature of episodic neurological conditions such as migraine and temporal lobe epilepsy. Auditory hallucinations are key symptoms in psychiatric disorders such as schizophrenic and other psychotic states, but they can also present with depressive and anxiety disorders, and in the context of virtually every psychiatric disorder of childhood. In fact hallucinations--usually simple and transient--are common in the general child populations. Auditory hallucinations become clinically significant when they occur as part of a medical disorder or in the context of acute psychotic states and schizophrenia, when they are frequent, complex, distressing and cause impairment. The treatment of clinically relevant hallucinations is that of the primary medical or psychiatric disorder. Occasionally they require treatment in their own right with psychological treatments, and only when these have been tried and fail, a careful trial of antipsychotic medication may be appropriate.