“Begin at the beginning”, the King said gravely, “and go on till you come to the end: then stop.” (Carroll 1869)¹
Alice is an 8-year-old girl who has been complaining that the furniture around her is tiny. These episodes last 5 to 10 minutes but it has happened three times today and is causing her distress. She is clinically well but has recently had a low-grade temperature and sore throat.
You review Alice with the trainee ACP. Alice’s airway, breathing and circulation examinations are normal. So is a detailed neurological examination: she’s alert with a normal cranial nerve exam, normal speech which has not changed, no limb weakness, normal gait and normal coordination. She also has a normal eye exam with normal visual acuity 6/6 in both eyes, normal eye movements, no nystagmus and no visual field deficit noted. She has no diplopia and no papilloedema.
Her throat is mildly red, but tonsils are not swollen and there is no exudate. She has a few small cervical lymph nodes.
You’re concerned this may be a brain tumour, and refer to the Headsmart guidelines. She has no red flags; persistent or recurrent headaches, vomiting, balance problems, abnormal eye movements, blurred or double vision, seizures, abnormal head position have been excluded, and the change in behaviour is short lived whilst appearing to see things smaller. You have a discussion with the radiologist about a CT/ MRI scan, and it is decided that an urgent scanning is not required immediately.
You order some standard bloods FBC, U&E’s, CRP to exclude infection, including an Epstein Barr screen. You also swab her throat for MC&S. A Fever Pain Score is 3, suggesting no indication for antibiotics for her throat symptoms.
As part of the assessment, you consider a mental health diagnosis. You are aware HEADSSS or SSHADESS evaluation can guide a focused psychosocial examination of a child’s emotional wellbeing. SSHADESS promotes resilience and emotional awareness, expanding knowledge of mental health, and in this case, you are keen to exclude acute psychosis or drug use. Given that Alice is 8, you modify the questions to make it more age appropriate. You focus on Alices strengths.
Alice reports her strengths are gymnastics and dance, and she is worried she won’t be able to do them if things look small. Her mum reports good school attendance, and she lives at home with mum, dad and a younger sister. Alice does not report any concerns with her emotions and appears in control. There is no access to drugs or known drug use in her household. Family history includes migraines, but Alice has never had any symptoms of migraines. There is no family history of epilepsy.
You wonder, could this be Alice in Wonderland Syndrome?
“Well, I never heard it before, but it sounds uncommon nonsense.”
What is Alice in Wonderland syndrome?
Alice in Wonderland Syndrome (AIWS) is a fascinating and rare disorder of perception. First described in 1955 by British psychiatrist John Todd – and sometimes referred to as Todd’s syndrome – it’s characterised by visual distortions, altered body image, and a skewed sense of time. Children may describe people or objects as unusually large or small, moving too fast, too slowly, or not at all.
AIWS takes its name from Alice’s Adventures in Wonderland, where Alice famously grows and shrinks and experiences the world in curious and confusing ways. But unlike hallucinations or illusions, the symptoms of AIWS are distortions of perception.
To clarify:
- Perceptual distortions, as seen in AIWS, sit somewhere in between. The brain receives sensory input, but processes it in a way that alters the experience – such as perceiving a hand as enormous, or the hallway as endlessly long.
- Hallucinations occur without any external stimulus – for example, hearing a voice when no one is there.
- Illusions are misinterpretations of a real external stimulus – like mistaking a shadow for a person.
Common Symptoms
More than 40 visual symptoms and 16 somaesthetic symptoms have been described in AIWS. Somaesthetic symptoms refer to altered perceptions of touch, body position, pain, temperature, or movement — essentially, how the body senses itself in space.
Symptoms typically last between 5 to 30 minutes in most instances, although they may last several days, or occur several times a day.
The most prevalent symptoms are listed with micropsia, the appearance of objects shrinking in size, occurring in 58.6% of cases and microtelepsia, the perception that objects are smaller and far away, in 4.1% of cases.
Diagnosis
Diagnosing Alice in Wonderland Syndrome isn’t straightforward. It doesn’t appear in the ICD-10 or DSM-5, and there’s no universally agreed clinical definition or diagnostic criteria. As a result, AIWS is often described as rare — but it may be under-recognised, partly due to stigma around potential psychiatric labels.
Diagnosis is largely one of exclusion. Once more serious causes have been ruled out, AIWS remains a clinical diagnosis. It has been associated with a range of underlying conditions, including migraine, temporal lobe epilepsy, brain tumours, and the use of psychoactive substances or recreational drugs. Infections have also been implicated, particularly Epstein–Barr virus (EBV), Coxsackie A virus, and influenza.
A review of case reports examining infectious causes of AIWS identified Epstein–Barr virus (EBV) as the most commonly reported pathogen. However, the findings are limited by under-reporting and the small number of published cases — larger studies are needed to draw firm conclusions.
AIWS is also closely linked with migraine. One report noted that around 10% of patients with migraine experience aura, and AIWS is considered by many to be a variant of migraine aura, particularly in those with a family history of migraine. In fact, migraine is the second most common cause of AIWS in children.
AIWS symptoms can emerge before, during, or after recognition of the underlying infection. This may reflect transient parenchymal oedema, acute encephalitis, or localised changes in cerebral blood flow.
Because a central nervous system disorder remains a differential diagnosis, the following baseline investigations are recommended:
- Blood tests: FBC, CRP, ESR → screen for infection/inflammation
- Neuroimaging: CT or preferably MRI → exclude tumour, stroke, demyelination, or vascular malformations
- EEG: exclude epilepsy
These tests are often normal. Given its infectious associations, patients may also present with concomitant systemic symptoms such as fever, sore throat, headache, fatigue, or reduced appetite.
Lumbar puncture is not usually indicated unless there is strong suspicion of CNS infection.
Drug screening may be appropriate depending on clinical context and local policy.
Pathophysiology
Alice In Wonderland Syndrome is thought to arise when the brain regions responsible for processing vision, body awareness, and time perception become temporarily disconnected or discoordinated. This disruption leads to the hallmark perceptual distortions seen in the syndrome.
Visual distortions
The visual cortex at the back of the brain has “special zones” for different jobs:
- V4 = colour
- V5 = movement
- Other areas = size, shape, position
If these zones misfire:
- Can’t see colour → everything looks gray
- Can’t see motion → things look frozen
- Misjudging size → objects/people seem tiny (micropsia) or huge (macropsia)
Body schema distortions:
- Brain areas that combine sensory info (mainly the parietal & temporal lobes) build a “map” of your body.
If these go wrong:
- A hand/leg might feel too big or too small
- The whole body might feel stretched or shrunken
- Might feel like you’re floating or split in two
Time distortions:
- The exact brain mechanism isn’t clear but likely comes from network mismatches in areas that control awareness and attention.
- This makes time feel sped up or slowed down.
- Vision areas → distorts what you see
- Somatosensory areas → distorts how your body feels
- Higher-order networks → distorts time
Neuroanatomically, there is a prevailing agreement identifying a “critical zone” at the intersection of the temporal, parietal, and occipital cortices, where somatosensory and visual information is integrated ⁷.
Treatments
“Who cares for you?” said Alice “You’re nothing but a pack of cards!”
You listen to Alice and check that there are no medications prescribed. You advise the family that all bloods taken today are routine. The plan for the future is to refer her to a neurologist for an EEG and MRI. However, you tell her you are aware of a similar phenomenon called Alice in Wonderland Syndrome, which fits her symptoms.
You signpost the family to The Brain Charity’s website https://www.thebraincharity.org.uk/condition/alice-in-wonderland-syndrome/ for more information. The family are grateful for your time.
Supportive care is key, and reassurance plays a central role. While AIWS itself is benign and self-limiting in most cases, it’s often linked to underlying conditions, as discussed above, so identifying and managing any root cause is essential.
A clear, age-appropriate explanation for the child, along with guidance for carers, can go a long way in reducing anxiety. Signposting to reliable resources can empower families and help normalise what can be a very unsettling experience.
AIWS has also been associated with certain medications. If symptoms appear after introducing a new medicine, it may be helpful to pause or review these with a prescribing clinician. Tracking symptom onset in relation to medication changes can help guide decision-making.
Take-home message
Alice in Wonderland Syndrome is a disorder of temporary perceptual distortions that lasts from 5 to 30 minutes.
The most common type is micropsia, seeing things smaller.
Exclude and treat underlying conditions: Epstein-Barr virus, migraines, epilepsy, infection, and new medications
Reassure the patient, no specific tests. Symptoms usually settle and are not harmful.
References
Carroll L. Alice’s Adventures in Wonderland. 1869.
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