Overview

Alice in Wonderland syndrome (AIWS), also called Todd’s syndrome or dysmetropsia, is a rare neurological condition that causes temporary, dramatic changes in how a person perceives their own body, visual objects, and sometimes the passage of time.

AIWS is named after the famous Lewis Carroll character because affected individuals may feel their body, or objects around them, suddenly grow, shrink, or become distorted—similar to Alice’s experiences in the book.

These episodes are usually brief, lasting from a few minutes to about 30 minutes, but can be highly disorienting. While the syndrome is rare and largely understudied, episodes are reported to happen most commonly in children, but can also affect adults.

How common is it?

AIWS is described as rare in medical literature, but true case numbers are uncertain:

• Only a few hundred cases have been formally documented worldwide, creating the impression it is extremely rare.
• Research in adolescents suggests that mild, brief episodes, such as altered size or distance perception, may be much more common, with up to 30% reporting some symptoms at least once.
• Among people with migraines, up to one in six may experience AIWS symptoms at least once.

Symptoms

AIWS episodes can involve a range of perceptual distortions, including:

• Visual changes: Objects or people may suddenly appear much larger (macropsia), much smaller (micropsia), farther away (teleopsia), or closer (pelopsia) than they really are.
• Body schema alterations: Parts of the body may seem out of proportion, such as hands or feet feeling too big or small.
• Temporal distortion: Time may seem to move unusually fast or slow.
• Auditory changes: Sounds may appear slowed down or sped up.
• Other effects: Some people experience derealization (feeling detached from reality), depersonalization (feeling detached from oneself), headaches, nausea, or dizziness.
• Associated features: In rare cases, seizures or hallucinations (seeing things that aren’t real) may occur, but most know the experience is not real. Although brief, these episodes can be unsettling and sometimes frightening.

Causes

The exact cause of AIWS is not fully understood, but it is most commonly associated with other medical conditions:

• Migraines are the leading known trigger in adults, especially migraines with aura.
• Viral infections, particularly Epstein-Barr virus, frequently trigger episodes in children.
• Other possible causes include epilepsy, certain fevers, encephalitis, brain tumors, and sometimes medications or significant stress.

Researchers believe that AIWS is related to changes in communication between the brain's visual and sensory pathways, particularly in the temporo-parietal-occipital junction, which alters how the brain interprets size, distance, or time.

Diagnosis

Diagnosing AIWS can be challenging because symptoms are brief and unpredictable. By the time a person seeks medical attention, the episode has often passed, and no abnormalities are visible during examination.

There is no single test to confirm AIWS. Instead, diagnosis is typically based on:

• Detailed symptom history: Descriptions of visual or sensory distortions are essential.
• Exclusion of other conditions: Doctors may order neurological imaging (MRI or CT scans), electroencephalograms (EEGs), or blood tests to rule out causes such as epilepsy, brain tumors, infections (e.g., Epstein-Barr virus), migraines.
• Pediatric diagnosis focuses on recent viral illnesses (like Epstein-Barr virus). In adults, a history of migraines with aura is often a key clue.

Because episodes are short-lived and often misunderstood, many individuals may never receive a formal diagnosis. However, the distinct pattern of sudden, temporary perceptual changes often helps guide clinicians toward identifying AIWS.

Treatment

There is no cure for AIWS, and in many cases, treatment may not be necessary. Most episodes resolve on their own, especially in children, where symptoms often fade over time.

When treatment is needed, it focuses on managing the underlying condition:

• Migraines: Preventive and acute migraine medications may help reduce AIWS episodes.
• Viral infections: Symptoms often improve as the infection resolves.
• Seizure-related cases: Anti-seizure medications may be prescribed if epilepsy is involved.
• Behavioral therapy: Techniques like habit reversal training and comprehensive behavioral intervention (CBIT) have shown promise in managing neurological symptoms in related disorders.

Prevention

There is currently no guaranteed way to prevent AIWS, as it is not a standalone disease but a symptom of other neurological or infectious conditions.

However, prevention efforts can focus on managing known triggers:

• Migraine control: Regular use of migraine medications and lifestyle adjustments (hydration, sleep hygiene, stress reduction) may lower the risk of AIWS episodes.
• Infection prevention: Practicing good hygiene, staying up-to-date on vaccinations, and avoiding exposure to contagious illnesses can reduce the risk of viral triggers.
• Stress and sleep: Maintaining healthy routines and managing stress may help reduce neurological sensitivity that contributes to AIWS.

While AIWS cannot be entirely prevented, early recognition and management of associated conditions can reduce the frequency and impact of episodes.