Alice In Wonderland Syndrome: Breaking Down Micropsia

Medically reviewed by April Justice, LICSW
Updated May 3, 2024by BetterHelp Editorial Team
Content warning: Please be advised, the below article might mention substance use-related topics that could be triggering to the reader. If you or someone you love is struggling with substance use, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357). Support is available 24/7. Please see our Get Help Now page for more immediate resources.

In 1955, Dr. John Todd discovered "The Syndrome of Alice in Wonderland" while observing patients with migraines and epilepsy. Dr. Todd described the symptoms of AWS as "illusory changes in the size, distance, or position of stationary objects in the subject's visual field, illusory feelings of levitation, and illusory alterations in the sense of the passage of time."  

Many patients he observed had experiences that reminded him of Alice's famous experiences in Wonderland when she ate or drank the delicacies presented to her, either growing to enormous sizes while everything around her seemed to shrink or shrinking until everything around her seemed enormous. 

Micropsia is one of the most common symptoms related to AIWS as detailed in Walsh and Hoyt’s Clinical Neuro Ophthalmology. It primarily presents through visual symptoms such as the distortion of objects. This distortion causes objects to appear much smaller than they are negatively impacting visual acuity. There are also variations of micropsia, including hemimicropsia, that can be evaluated using tools like a controlled size comparison task. Micropsia and its variants may distort visual perception and can feel unsettling for those who experience it. These feelings may persist even if a person knows how large an object is in real life as to them, it may appear significantly altered in their right or left visual field.

Afraid your perceptions aren’t in proportion with reality?

What is Alice In Wonderland syndrome? 

Alice in Wonderland Syndrome is the name of the umbrella covering many optical-related disorders and visual disturbances, including macropsia, metamorphopsia, and pelopsia. One of the most common causes of these disorders is macular degeneration, a condition impacting the retina of a patient. While this condition can occur earlier in life, age-related macular degeneration may be more common (particularly for those over 50). These conditions may cause images to appear distorted and objects smaller or larger than in real life.

A famous study surveyed 48 individuals with confirmed Alice in Wonderland Syndrome. Out of the 48 people examined, 69% reported experiencing symptoms of micropsia instead of the other visually impairing conditions that AIWS can produce. They also found that one-third of the participants surveyed reported that their symptoms continued over a span of time. However, most of the examined participants reported having symptoms and disease progression that continued to appear throughout their lives. Those living with micropsia often experience these manifestations in the evening or after sundown.

Many who experience micropsia can cognitively determine that the objects around them aren't warped, but the brain still registers the size discrepancy as a sensory experience. For example, an individual may perceive an observed object as tiny but understand that it will be averagely sized when they touch it.  

Individuals who experience micropsia may feel like their body is disproportionate and may experience convulsing or severe trembling. They may experience hallucinations and seizures, which can lead to excessive fatigue. Some people also report feelings of levitation or flying. There is a link between micropsia and dissociative disorders, AIWS can feel like a frightening out of body experience whereas what the individual perceived as normal is not reality.

What causes Alice In Wonderland syndrome and its associated visual system changes? 

In many cases, neurological concerns like migraines and seizures affect the probability that AIWS will manifest. In addition, AIWS may also be caused by substance use disorders. Drug use can cause AIWS, especially if an individual is using hallucinogenic drugs. Additionally, withdrawal symptoms that occur in detoxified substance users can include hallucinations including AWIS symptoms. Because individuals who experience AWS perceive their bodies and the objects around them as distorted, this condition can cause anxiety, fear, and discomfort. Micropsia is not limited to one age or demographic. 

There are a variety of factors that can contribute to the onset of micropsia, including, but not limited to:

  • Bacterial and viral infections such as Epstein-Barr virus infection, typhoid fever, Lyme disease, scarlet fever, chicken pox, and shingles 
  • Central serous chorioretinopathy (CSCR), which can cause a detachment of the neurosensory retina
  • A migraine attack or other types of headaches, like cluster headaches and abdominal migraines
  • Retinal edema, which can cause a dislocation of the receptor cells
  • Temporal lobe seizures caused by conditions such as epilepsy
  • Strokes including right temporoparietal infarction
  • Recreational or hallucinogenic substances 
  • Some prescription medications
  • Degenerative brain and nervous system diseases such as Creutzfeldt-Jakob disease or multiple sclerosis
  • Brain tumors and lesions affecting the brain
  • Psychological disorders such as schizophrenia or bipolar disorder, among others 

Other symptoms of Micropsia (unrelated changes in visual acuity)

Micropsia often involves multiple side effects that can leave those with the condition significantly impacted. Migraines are one of the most common symptoms before and after an episode of micropsia. An episode can also alter one's perception of time, speed, and senses. Although symptoms of micropsia often occur in the evening or at night, some individuals may experience distortions throughout the day. This distortion can cause paranoia, anxiety, and restlessness.

Diagnosis and treatment

There are many tools that a doctor can use to diagnose the cause of AIWS. Consult with a neurologist if you are experiencing symptoms. 

Tests and brain monitoring, such as MRI and CT scans, can reveal abnormalities or structural issues that can cause AIWS. Also, depending on the symptoms and suspected cause, a doctor may request a spinal tap to test the spinal fluid for signs of infection. 

An EEG (electroencephalogram) can analyze brain activity to diagnose conditions like occipital lobe epilepsy and seizures that can cause AIWS. A doctor may also request tests that measure how the human eye interacts with the brain. 

The treatment for AIWS may also vary according to the cause and diagnosis. Adults and children who experience intense and current migraines may be prescribed migraine medication, as people with epilepsy might undergo treatment for their seizures.  

If AIWS is caused by a psychological or psychiatric disorder such as schizophrenia or depressive disorder, or if it results from a substance use concern, psychotherapy may be the most beneficial option. Talking to a sleep specialist can help you get started if your symptoms occur during sleep.

Afraid your perceptions aren’t in proportion with reality?

Treatment options 

Although micropsia can be a rare vision condition, many individuals live with this syndrome. Understanding the underlying causes and symptoms makes it possible to get effective treatment for AIWS. 

If you feel that you have symptoms of AIWS and micropsia, consult with a neurologist or talk to your primary care provider for a referral. They may conduct the tests and examinations necessary to determine the cause and set a course of treatment. Depending upon the cause, part of your treatment may include taking dietary supplements, specialty eyeglasses, or therapy.  

For some, visiting a therapist in person is difficult, and meeting with a therapist through a computer screen may be a better option. Barriers may occur due to availability issues, scheduling issues, or issues related to social anxiety. Many find that online counseling offered on platforms like BetterHelp is a beneficial solution for those barriers to treatment. 

In addition, research shows that internet-based therapy can be as effective as in-person treatment for mental health conditions like anxiety, depression, and trauma-related disorders. When you use online therapy platforms, you can choose between phone, video, or live chat sessions with your therapist and get on the schedule quickly. If your therapist believes your concern is due to a medical issue, they may also suggest you seek medical advice for your symptoms. 

If you are experiencing trauma, support is available. Please see our Get Help Now page for more resources.

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Alice in Wonderland Syndrome is a rare neurological condition that can cause the feeling of being larger or smaller than your environment, strange bodily sensations, and dissociation. If you have experienced symptoms of this condition, consider contacting your primary care physician for further guidance. You can also talk to a therapist if this condition is causing you anxiety or seems related to a mental illness. You're not alone, and support is available.

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