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NEWS FROM THE AAN ANNUAL MEETING: Alice in Wonderland Syndrome Linked to Migraine, Virus

Susman, Ed

doi: 10.1097/01.NT.0000416331.76939.8e
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JOHN ROBERT LANSKA, in front of his poster at the AAN annual meeting

JOHN ROBERT LANSKA, in front of his poster at the AAN annual meeting

A 17-year-old author of a study poster offers an analysis of clinical cases of Alice in Wonderland syndrome in the medical literature.

NEW ORLEANS—At age 17, John Robert Lanska was likely the youngest author of a poster accepted here at the last AAN annual meeting. But then again, John, who recently graduated as the class valedictorian from Tomah High School in Wisconsin, had some inspiration close to home — his father is Douglas J. Lanska, MD, a staff neurologist and former chief of neurology at the Veterans Affairs Medical Center in Tomah.

John's poster, accepted as a Medical Student Presentation, offers an analysis of research into an intriguing but rare behavioral neurology condition — Alice in Wonderland syndrome — an undertaking inspired by an English assignment for his Advanced Placement English composition class. John, who aspires to be a physician some day, wrote his essay about the perceptual disorders experienced by Alice in Lewis Carroll's classic Alice in Wonderland, and how they might relate to clinical disorders in patients with neurological diseases.

In reading about the syndrome, he noticed there was considerable variability in the types of perceptual disorders described. With help from his father, John gained access to and surveyed the medical literature for references to the syndrome. The condition, thought to be caused by migraine or viral infection, gives patients a dysmorphic view of other people's bodies and their own — recalling the adventures of Alice in the novel — and hence the name of the disorder.

The syndrome was described first in1955 by the English psychiatrist John Todd, who named the perceptual disorder of altered body image for the heroine of Lewis Carroll's novel. Dr. Todd defined Alice in Wonderland syndrome as “self-experienced paroxysmal body-image illusions involving distortions of size, mass, shape, or position,” John told Neurology Today.

For his poster, John identified 80 cases — and three types — of the disorder in the medical literature. In Type A, people think of their own body parts as distorted. In Type B, patients see other people's figures as distorted; for example, they might see other people as too little, too big, too near, too far, or distorted in some way. Those with Type C perceive themselves and others in a distorted way.

John said that most of the cases involved children about 8 to 10 years of age who were being treated for Epstein-Barr virus infection and older individuals who suffered from migraine. In cases in which gender was identified, about half were boys or men, but there was no difference between types.

“Cases of Alice in Wonderland syndrome are not that common, but they do exist,” explained Dr. Lanska, who observed his son fielding questions by the poster area. “It's much more common in kids, usually around 9 or 10 years of age, and comes to our attention because these children are reporting crazy things to their parents. Treatment is symptomatic. Patients get better as the condition that causes it gets better, such as Epstein-Barr virus and migraine. When the illness or migraine goes away, the Alice in Wonderland syndrome resolves as well. It's a temporary phenomenon, just like it was for Alice.”

In the literature, all Alice-in-Wonderland syndrome symptoms that were believed to be linked to Epstein-Barr virus occurred in patients under the age of 20 — peaking with 13 cases among nine- to 10-year-olds. The eight cases linked to migraine occurred in patients who were in their late teens to 40s.

Hallucinogenic drugs can cause visual distortions and hallucinations as well. Dr. Lanska said it was thought that some of the cases of Alice in Wonderland syndrome were related to adverse reactions to various medications, legal and illegal.

Indeed, at the meeting, one geriatric neurologist told John and Dr. Lanska that he had seen only one case of Alice in Wonderland syndrome in his career, while a pediatric neurologist shared that she had seen more than 10 cases, typically associated with Epstein-Barr infections, Dr. Lanska said in an e-mail.

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“It is a very unusual syndrome,” said Kenneth M. Heilman, MD, the James E. Rooks Jr. Distinguished Professor of Neurology & Health Psychology at the University of Florida Center for Movement Disorders and Neurorestoration in Gainesville, who was not involved in the study.

Migraine, certain drugs, and epilepsy can also cause visual distortions, although these distortions often differ from the kind seen in Alice in Wonderland syndrome in both etiology and symptomatology, Dr. Heilman told Neurology Today.

“Many patients with visual migraine have hallucinations, where they may see things such as wavy lines and colors. These symptoms are thought to be related to physiologic changes in the occipital cortex, the vision portion of the brain. The areas of the brain that appear to generate memories or representations of the body are in the posterior parietal-occipital region or the posterior temporal occipital region; migraine may cause alterations in these regions.”

Dr. Heilman also noted that “occasionally, patients with focal epilepsy may perceive items as looking larger (macroscopia) or smaller (microscopia) than their actual size.”

Alice in Wonderland syndrome might manifest in individuals who seek surgery to correct body parts that may seem to them to be too small or too large, according to Dr. Heilman. “Clearly, people with anorexia nervosa see themselves as obese, and many people who get plastic surgery see their body parts as more malformed than do other people and thus often get operations such as rhinoplasty,” he said.

“However, these distortions may have another mechanism,” Dr. Heilman noted. “When a person focuses on an object or portion of an object, certain characteristics of that object — such as size — may look bigger or smaller than an equal-sized object that is unattended.

“For example, when you drive down a road you have never been on before, it appears longer than when you return on this same road. The reason for this misperception is that when it is novel, you pay more attention to the road. We are now testing the hypothesis that people who see their body or parts of the body as being larger than they actually are may be continually focusing attention on these body parts.”

Back in Wisconsin, John Robert Lanska, the youngest poster presenter this year, is focusing on his future. He plans to attend University of Wisconsin at Eau Claire in the fall, and major in chemistry and jazz piano. Having earned several highly competitive merit-based scholarship awards, including the Wisconsin Academic Excellence Scholarship award and the Herb Kohl Foundation Excellence Scholarship, he is well on his way. He hopes eventually to follow his father into medicine but neurology is not currently the top choice; for now, he has his sights on cardiology or sports medicine.

©2012 American Academy of Neurology