'Alice in Wonderland' syndrome and Lilliputian hallucinations in a patient with a substance-related disorder

Alice in Wonderland syndrome as aura of migraine

Alice in Wonderland syndrome (AIWS), named for Lewis Carroll's titular character, is a disorder characterized by transient episodes of visual hallucinations and perceptual distortions, during which objects or body parts are perceived as altered in various ways (metamorphopsia), including enlargement (macropsia) or reduction (micropsia) in the perceived size of a form. Migraine aura is a transient neurological symptom that most commonly involves the visual fields and occurs before the headache phase. Aura symptoms include the perception of flashing lights that begin in the center of vision and expand in jagged patterns out into the periphery. Symptoms may be somatosensory, such as numbness and tingling in the lips or fingers. They may also involve a profound alteration of the perception of space and time (the "Alice in Wonderland" syndrome). In this article, we present a child had Alice in Wonderland syndrome as aura of migraine.

The Alice in Wonderland syndrome

The Alice in Wonderland syndrome is a term applied to altered bizarre perceptions of size and shapes of a patient's body and illusions of changes in the forms, dimensions, and motions of objects that a patient with this syndrome encounters. These metamorphopsias arise during complex partial seizures, migraine headaches, infections, and intoxications. The illusions and hallucinations resemble the strange phenomena that Alice experienced in Lewis Carroll's Alice's Adventures in Wonderland. Charles Lutwidge Dodgson, whose nom de plume was Lewis Carroll, experienced metamorphopsias. He described them in the story that he wrote for Alice Liddell and her two sisters after he spun a tale about a long and strange dream that the fictional Alice had on a warm summer day. The author of this chapter suggests that Dodgson suffered from migraine headaches and used these experiences to weave an amusing tale for Alice Liddell. The chapter also discusses the neurology of mercury poisoning affecting the behavior of Mad Hatter character. The author suggests that the ever-somnolent Dormouse suffered from excessive daytime sleepiness due to obstructive sleep apnea.

Alice-in-Wonderland syndrome--a case-based update and long-term outcome in nine children

PURPOSE

There are some reports of so-called Alice-in-Wonderland syndrome mostly concerning differential diagnosis, association with a variety of infectious diseases and even some case reports on functional imaging. Long-term data are rare.

METHODS

Nine boys aged 6 to 11 years that had been diagnosed with Alice-in-Wonderland syndrome between 2003 and 2008 were contacted for a long-term follow-up study in summer, 2009, with a mean follow-up of 4.6 years.

RESULTS

At the time of the follow-up study, all children were in good general and mental health. Symptoms of Alice-in-Wonderland syndrome had ceased within weeks or months. In two patients, episodes of metamorphopsia returned after a symptom-free latency of 3 years and 1 year, respectively. Five children had a family history of migraine or epilepsy. In one case, the father was reported to have experienced similar symptoms when he was a child.

CONCLUSION

Our follow-up study shows that Alice-in-Wonderland is most likely a benign, self-terminating childhood condition, although occasional recurrences of symptoms are possible.

Treatment of Alice in Wonderland syndrome and verbal auditory hallucinations using repetitive transcranial magnetic stimulation: a case report with fMRI findings

BACKGROUND

Alice in Wonderland syndrome (AIWS) is a rare cluster of CNS symptoms characterized by visual distortions (i.e. metamorphopsias), body image distortions, time distortions, and déjà experiences. Verbal auditory hallucinations (VAHs) are the most prevalent type of hallucination in adults with or without a history of psychiatric illness. Here, we report the case of a woman with AIWS, long-lasting VAHs, and various additional perceptual and mood symptoms.

METHODS

Semi-structured interviews were used to assess symptoms, and functional MRI (fMRI) was employed to localize cerebral activity during self-reported VAHs. Treatment consisted of repetitive transcranial magnetic stimulation (rTMS) at a frequency of 1 Hz at T3P3, overlying Brodmann's area 40.

RESULTS

Activation during VAHs was observed bilaterally in the basal ganglia, the primary auditory cortex, the association auditory cortex, the temporal poles, and the anterior cingulated gyrus. The left and right inferior frontal gyri (Broca's area and its contralateral homologue) were involved, along with the dorsolateral prefrontal cortex. Interestingly, synchronized activation was observed in the primary visual cortex (areas V1 and V2), and the bilateral dorsal visual cortex. The higher visual association cortex also showed significant, but less prominent, activation. During the second week of rTMS treatment, not only the VAHs, but also the other sensory deceptions/distortions and mood symptoms showed complete remission. The patient remained free of any symptoms during a 4-month follow-up phase. After 8 months, when many of the original symptoms had returned, a second treatment phase with rTMS was again followed by complete remission.

CONCLUSIONS

This case indicates that VAHs and metamorphopsias in AIWS are associated with synchronized activation in both auditory and visual cortices. It also indicates that local rTMS treatment may have global therapeutic effects, suggesting an effect on multiple brain regions in a distributed network. Although a placebo effect cannot be ruled out, this case warrants further investigation of the effects of rTMS treatment in AIWS.

A migraine variant with abdominal colic and Alice in Wonderland syndrome: a case report and review

BACKGROUND

Abdominal migraine is a commonly described migraine variant in children and young adults, but associations with Alice in Wonderland syndrome and lilliputian hallucinations are exceptional.

CASE PRESENTATION

A 20 years-old male experienced frequent and prolonged attacks of abdominal colic associated with autonomic manifestations started at the age of ten. At the age of 17, he additionally described prolonged attacks (>or= 7 days) of distortions of shape, size or position of objects or subjects. He said "Quite suddenly, objects appear small and distant (teliopsia) or large and close (peliopsia). I feel as I am getting shorter and smaller "shrinking" and also the size of persons are not longer than my index finger (a lilliputian proportion). Sometimes I see the blind in the window or the television getting up and down, or my leg or arm is swinging. I may hear the voices of people quite loud and close or faint and far. Occasionally, I experience attacks of migrainous headache associated with eye redness, flashes of lights and a feeling of giddiness. I am always conscious to the intangible changes in myself and my environment". There is a strong family history of common migraine. Clinical examination, brain-MRI and EEG were normal. Transcranial magnetic stimulation and evoked potentials revealed enhanced cortical excitability in multiple brain regions. Treatment with valproate resulted in marked improvement of all clinical and neurophysiological abnormalities.

CONCLUSIONS

The association between the two migraine variants (abdominal migraine and Alice in Wonderland Syndrome) might have clinical, pathophysiological and management implications. I think this is the first description in the literature.

Neuropsychiatry of complex visual hallucinations

OBJECTIVE

To describe the phenomenology and pathophysiology of complex visual hallucinations (CVH) in various organic states, in particular Charles Bonnet syndrome and peduncular hallucinosis.

METHOD

Three cases of CVH in the setting of pontine infarction, thalamic infarction and temporoparietal epileptiform activity are presented and the available psychiatric, neurological and biological literature on the structures of the central nervous system involved in producing hallucinatory states is reviewed.

RESULTS

Complex visual hallucinations can arise from a variety of processes involving the retinogeniculocalcarine tract, or ascending brainstem modulatory structures. The cortical activity responsible for hallucinations results from altered or reduced input into these regions, or a loss of ascending inhibition of their afferent pathways.

CONCLUSIONS

A significant degree of overlaps exists between the concepts of Charles Bonnet syndrome and peduncular hallucinosis. The fluidity of these eponymous syndromes reduces their validity and meaning, and may result in an inappropriate attribution of the underlying pathology. An understanding of how differing pathologies may produce CVH allows for the appropriate tailoring of treatment, depending on the site and nature of the lesion and content of perceptual disturbance.

Komplexe Halluzinationen im Migräneanfall bei 10-jährigem Patienten - eine Fallbeschreibung und Übersichtsarbeit

Zusammenfassung: Fragestellung: Die Migräne ist bei Kindern mit einer Prävalenz von drei bis zehn Prozent eine häufige Erkrankung. Visuelle Auren sind als Charakteristikum der klassischen Migräne in der Literatur ausgiebig beschrieben. Vornehmlich handelt es sich um primäre Halluzinationen, Beschreibungen komplexer Halluzinationen hingegen sind kaum zu finden. Die vorliegende kasuistische Darstellung beinhaltet nach unserem Wissen das jüngste beschriebene Alter von komplexen Halluzinationen während einer Migräneattacke. Mögliche pathophysiologische Mechanismen und differentialdiagnostische Überlegungen werden auf Grundlage der bestehenden Literatur diskutiert. Methode: Dargelegt wird die Kasuistik eines 10-jährigen Patienten, welcher von einer komplexen visuellen Halluzination bei einer Migräneattacke berichtet. Es werden Symptomatik, Vorgeschichte sowie diagnostische Schritte dargestellt. Differentialdiagnostisch zu einer migränösen Aura werden das «Alice-in-Wonderland-Syndrom», «Liliputanische Halluzinationen», die Basilarmigräne sowie eine epileptische Genese diskutiert. Schlussfolgerung: Für komplexe Halluzinationen bei Migräne ist vermutlich ein analoger Pathomechanismus zu den primären Halluzinationen der migränösen Aura anzunehmen, so dass durch die vorliegende Arbeit die große Variabilität der migränösen Aura erneut unterstrichen wird.