Australasian Science: Australia's authority on science since 1938

Curiouser and Curiouser

By Tim Hannan

A new case of Alice in Wonderland syndrome draws attention to how little is known about perceived distortions of body size.

If judged by the marked increase in its press coverage, it might be assumed that a pandemic of Alice in Wonderland syndrome is imminent. In December, the Daily Mail in Britain profiled a young woman who has, from the age of 5 years, suffered transient episodes in which she perceives her body to grow while objects shrink around her. The condition was also characterised in the television series House, and the medical literature has recently featured a number of clinical reviews and case reports. Yet, despite this increased attention, little progress has made in understanding the cause of these bizarre symptoms, or in identifying any effective treatment.

The syndrome was first documented in 1952 by an American physician, who described the experiences of seven adult migraine sufferers, all of whom he noted to be without evident neurological or psychological illness other than migraine headaches. One patient described the sensation of feeling only one foot tall, another of seeming abnormally tall, and a third wrote of being both short and wide, “as the reflection in one of those broadening mirrors one sees in carnivals”. Another patient labelled this last illusion as her “Tweedle-Dum or Tweedle-Dee feeling”, after characters in Through the Looking Glass. Others reported the sensation of a body part being elongated, with one diarising her symptoms as “I get all tired out from pulling my head down from the ceiling. My head feels like a balloon; my neck stretches and my head goes to the ceiling. I’ve been pulling it down all night long.” Some noted that the perceived distortion was so vivid that, on catching sight of their normally-sized bodies in a mirror, they were shocked to discover that their experience was illusory.

Noting the similarity of these episodes to events and characters in the writings of Lewis Carroll, himself a migraine sufferer, an English psychiatrist proposed that the condition be named after the author’s eater of magical body-changing cakes and mushrooms. To date, more than 80 cases have been detailed in the medical literature, with the defining symptom being metamorphopsia, in which either one’s body or other objects are experienced as distorted in size, shape, or inclination. Commonly co-occurring symptoms include polyopia (in which an object is perceived as twinned), palinopsia ( the persistence of a visual image following removal of the object), and dissociative experiences such as depersonalisation or derealisation. Some report the illusion of levitation, and others alterations in their sense of the passage of time.

Episodes range from a few minutes to an hour or more, and occur with equal frequency in both sexes. Around two-thirds of sufferers are children, with many of the adults noting that their first episode had occurred in childhood. Symptom frequency is reported to decrease with age.

The suspected causes are neurological, including infections, epilepsy and migraine headaches, although some cases appear to have no associated neurological condition. Neuroimaging has yet to identify a consistent cerebral pathology and, given the multiple aetiologies, it is likely that pathology in diffuse brain regions may be responsible.

Nevertheless, the leading hypothesis is that disruption to regions surrounding the visual pathways produce disturbances in aspects of object perception. The visual cortex is unable to “explain” the object’s retinal projection, and the brain’s attempt to resolve the inconsistent information results in the sensation of distorted body size or shape.

Patients’ reports highlight the distress and confusion that accompany episodes, and this is often exacerbated by delays in accurate diagnosis, especially if accompanied by a clinician’s presumption of a psychiatric illness, traumatic aetiology or malingered symptomatology. Indeed, the bizarre quality of the Alice in Wonderland syndrome – and even its name – may minimise general appreciation of the significant impact it has on daily functioning. For readers of the Daily Mail, this appreciation would not have been enhanced by the paper’s decision to dress the woman in an apron and photograph her among teapots and playing cards.

As the 150th anniversary of the publication of Carroll’s classic book approaches, interest in Alice in Wonderland syndrome is likely to increase. Advances in genetics and neuroimaging may yet shed light on its cause and pathology, which may in turn improve our understanding of the misperception of body size and shape observed in eating disorders, body dysmorphic disorder and Koro.

Tim Hannan is an Associate Professor of Clinical Psychology at Charles Sturt University, and the President of the Australian Psychological Society.