Health and Medicine
PUBLISHED
If you have read or watched Lewis Carroll’s Alice’s Adventures in Wonderland, then you might remember when Alice first falls down the rabbit hole. She finds herself in a room with lots of doors, one leading to a lovely garden that she’s keen to escape to. The trouble is, she’s too big to fit through the door.
Luckily for our hapless heroine, there’s a bottle of questionable liquid nearby, helpfully labeled “DRINK ME”. According to Carroll, it has the bizarre flavor of “cherry-tart, custard, pine-apple, roast turkey, coffee, and hot buttered toast” and the effect of shrinking her to a tiny size.
You know the rest – she’s forgotten to grab the key to the door and has to eat some conveniently placed cake that makes her tall again, only it all goes a bit far.
While all these things are happening to Alice, she’s known to exclaim, “Curiouser and curiouser!”
But if you started seeing yourself changing size before your eyes, it’s possible your language would be less measured.
Drink me, eat me
Alice in Wonderland syndrome (AIWS) is a real, if rare, psychiatric condition whereby this happens to people in real life – they start to hallucinate things being the wrong size, most often parts of their own or others' bodies.
In a case report from earlier this year, a Japanese physician recounts the story of a young boy who was diagnosed with AIWS after a viral infection.
The boy, described as being in “middle childhood”, suffered an episode of fever accompanied by auditory hallucinations that sound quite terrifying: “he suddenly shouted that bombs were falling and urged his family to take shelter, behaving as if he were in a war zone. That night, he awoke 5–6 times due to the loud sounds of the ‘drum and fireworks’ in his head.”
Tests for flu and COVID-19 were negative, but on day four of his illness he was diagnosed with an adenovirus infection. These viruses infect people all year round and are a common cause of cold or flu-like symptoms, sore throats, bronchitis, and gastroenteritis.
The auditory hallucinations continued for almost a month, even after the initial illness resolved. Later, the boy reported that his mother’s face appeared abnormally large and his father’s face appeared square. Then, he started seeing objects as smaller than they actually were.
By this point, there were no signs of infection anymore, so the clinic the boy visited could rule out adenovirus as a cause, and there were no signs of migraine or epilepsy.
“The hallucinations were persistent and lucid, and the visual distortions were consistent with the characteristic size and shape distortions of AIWS,” the case report reads.
Thankfully, the boy’s condition resolved shortly afterwards.
A first for Alice in Wonderland syndrome
Infectious disease has been known to cause episodes of AIWS in the past, but the author of the case report, Dr Takanori Abe, writes that this appears to be the first documented case of the condition following adenovirus infection.
Another factor that may have been relevant is that the boy was subsequently diagnosed with ADHD.
The condition had not previously been recognized, and he had not been taking any medication. Abe writes that “although ADHD has not been reported as a direct cause of AIWS, previous studies have shown that individuals with ADHD may exhibit altered perceptual processing, including differences in visual perception, such as susceptibility to visual illusions.”
In addition, Abe speculates that underlying psychological stress could also have contributed to the boy’s symptoms.
“Currently, no specific treatments exist for AIWS. Although AIWS treatment should target the underlying condition, simply reassuring patients that their symptoms do not necessarily indicate an impending psychiatric disorder can substantially alleviate anxiety.”
This was echoed in a 2016 review, which found that “reassurance that the symptoms themselves are not harmful seems to suffice in about 50 percent of the cases.”
The origins of Alice in Wonderland syndrome
There are still a lot of unknowns around AIWS, which was only first described in the literature in 1955 by psychiatrist John Todd. As this case shows, it can follow an infection but has also been linked to brain tumors, brain injury, and migraine, among other causes.
A 2024 study put some of the pieces together. Looking back at brain scans from 37 people with AIWS and comparing these with scans from healthy controls and people with other neuropsychiatric disorders, the authors discovered some patterns.
AIWS was associated with lesions in parts of the brain connected to two major hubs: the right extrastriate body area, which is associated with visual processing, and the left inferior parietal lobe, which is activated when we try to determine an object’s size.
More research is still needed. As Abe writes, “Accumulating similar case reports would aid in elucidating the pathophysiology of perceptual disturbances following adenovirus infection.”
AIWS is rare, and it’s not the only unusual condition in which our perception of our environment goes awry.
Ever felt like time is moving faster than it should? For people with tachysensia, sometimes called “fast feeling”, episodes like that happen regularly, but science is only just starting to catch up with what’s going on.
The case report is published in BMJ Case Reports.
