Alice in Wonderland syndrome (AIWS) is a disorder that manifests in the form of distorted experience of time, visual perception and body schema (Blom, 2016). Initially discovered by Dr. John Todd in 1955 AIWS was famously known as Todd's syndrome. However, earlier (1952) Caro Lippman had identified and documented traits that resembled Alice in Wonderland syndrome (Blom, 2016). AIWS results in cardinal alteration which manifests in an imbalance between the external world and the representation of self. Historically, this phenomenon was referred to as a sign of cerebral asthenopia which is an unusual fatigability of the perception senses of an individual. Patients, therefore, experience an erroneous perception of self in terms of body size with respect o the surrounding environment. Their perception of self may also occur in terms of a rework of the external surrounding concerning their own body. This research looks at the symptoms of AIWS, theoretical frameworks surrounding, statistical pertinent and controversies surrounding the psychological disorder.
Symptoms and Complications
AIWS is common in children. The symptoms of AIWS are quite ambiguous, and most physicians and practitioners may fail to identify the condition. AIWS has been establishing to portray at least 42 visual symptoms. Apart from visual symptoms AIWS also has 16 non-visual and somesthetic symptoms (Blom, 2016). These symptoms arise from the distortion of sensory perception. Twenty-five hallucinations are experienced when appropriate stimulus between the individual and the outside world. The latter results in hallucinations such as seeing an animal which in actual sense is non-existent or hearing voices when no one is calling. Illusions, on the other hand, have a source from the outside; however, they are misinterpreted by the individual to create frightening imaginations (Blom, 2016). For example, the blowing of wind can be interpreted as someone opening the window by an individual with AIWS.
Apart from illusions individuals with AIWS also experience distortions which are sensory impressions which influence highly specific parts of the sensor input picture (Blom, 2016). Individuals with AIWS may perceive lines that are straight as wavy - dysmorphism; vertical lines may be viewed as slanted-plagiopsia while stationary objects are seen to move- kinetopsia (Blom, 2016). Additionally, individuals with AIWS may see the eyes of others as unnaturally big - prosopometamorphopsia (Blom, 2016). Prosopometamorphopsia is responsible for the altered personal image of the body. The individuals perceive certain parts of the body in an altered fashion. The head seems to be bigger than the rest of the body as the hands appear longer. Other parts of the body may also be extremely exaggerated in terms of growth- either too short or long. Also, as they hallucinate individuals develop strong feelings and wrong impressions about particular things and events that may not be existing.
The effect on visual perception (micropsia and macropsia) of individuals is among the dominant symptoms of AIWS. Studies describe the two as the most prevalent symptoms with 58.6% and 45.0% of AIWS individuals showing signs of micropsia and macropsia respectively (Blom, 2016). The symptoms of AIWS occur within a short period, usually minutes or days. When an individual is fixated on an object metamorphopsias which results in impairment of vision happens within seconds of a few minutes. During the temporary delay, objects become distorted despite the perceptual process remaining untampered. However, sometimes the symptoms may persist for years.
According to Blom (2016), AIWS contributes significantly to uncontrolled migraine. Individuals with the condition lose a sense of time as time either passes slowly or at a rapid rate. The migraine also comes with nausea and vomiting. Apart from being the symptom of the condition headaches and vomiting are also identified as the main triggers of the hallucinations (Blom, 2016).
The auditory and tactile perception of the individual also gets warped. Eventual they may lose control of their limb and total coordination. These symptoms are attributed to the act that muscles feel they are reacting involuntarily as the vision is impaired. This altered sense of reality in addition to the effect on the auditory canal is likely to result in a loss of balance vital for walking and balancing. Individuals, therefore, feel uncoordinated and have difficulty walking around as they would under normal circumstances.
Individuals with AIWS also portray epileptic characteristics. Epilepsy and brain tumors are among the causal factors which trigger AIWS. AIWS is directly linked with cases of acute disseminated encephalomyelitis (Blom, 2016). Acute disseminated encephalomyelitis (ADEM) is an immune-mediated inflammatory condition predominantly affecting the white matter in the spinal code and the brain (Tenembaum et al. 2007). The manifestation of ADEM is accompanied with acute-onset encephalopathy which triggers polyfocal neurologic deficits which are self-limiting (Tenembaum et al. 2007). ADEM can be confused with other pathological and clinical acute demyelinating syndromes affecting children such as multiple sclerosis. Apart from Acute disseminated encephalomyelitis, AIWS is also linked with infectious diseases which act as triggers and side effects of the syndrome. These diseases entail cytomegalovirus infection, varicella, Lyme's disease, H1N1 influenza virus infection, Epstein-Barr virus infection, Coxsackie virus infection, and Strep Pharyngo-amygdalitis (Palacios-Sanchez et al. 2018).
Statistical Trends of AIWS
Migraine is identified as the predominant symptom affecting at least 15% of patients. Another cross-sectional study of 3,224 high school students discovered a six-month prevalence rate of 2.5% for the protracted duration, 3.9% for macropsia, 3.8% for micropsia and 1.3% for the quick-motion (Blom, 2016). A study of 1,480 adolescents discovered that there is a lifetime prevalence of micropsia and macropsia. Females were profoundly affected by the condition more than male at 6.2% and 5.6% respectively (Blom, 2016). Another study comprised of 297 individuals with an average age range of 25.7 years found that prevalence rates of for teleopsia are at 30.3% dysmorphopsia at 18.5% macropsia at 15.1% and micropsia at 14.1% (Blom, 2016). This study also showed that 38.9% of individuals affected portrayed a single symptom, 33.6% two symptoms, 10.6% three symptoms and 16.8% more than three symptoms (Blom, 2016). The trend depicts a possible stochastic process where the presence of a particular symptom lowers the probability of the patient having other symptoms.
A series of diagnosed cases of 9 children from 2003 to 2008 were also observed to determine the long-term consequences of AIWS. The study listed in Weidenfeld and Borusiak report concludes that the syndrome has no specific treatment and neither does it require long term follow up (Palacios-Sanchez et al. 2018). Additionally, there is an acute manifestation of occasional symptoms which may be confused with severe medical conditions. Other medical conditions must, therefore, be ruled out. Ten studies have linked AIWS with depression, with treatment using positron emission tomography (PET) suggesting a biological substrate of depression in the syndrome. A case of a Japanese 63-year-old male who showed signs of metabolic alterations in the cortex region mainly occipital, parietal and frontal areas revealed imaging abnormalities could be resolved after treatment. This etiology is the same as in depressed patients particularly regarding the altered visual and prefrontal cortexes (Palacios-Sanchez et al. 2018).
The diagnosis made by analyzing the complete history of the patient, physical examination taking into consideration the neurologic, ophthalmic and otologic changes and being aware of the potential symptoms of AIWS. A brain MRI and EEG examination should be able to differentiate the disorder from the central origin despite the low chances of finding demonstrable lesions. When a tomography brain scan is conducted on an individual with metamorphopsia, a diminished bode flow in the occipital and temporal lobes is portrayed (Marino et al. 2010). Also, throughout micropsia stages of AIWS, patients MRI indicates hypoactivation of the extrastriate and primary regions of the visual cortex.
Differential diagnosis of the syndrome is complicated as it entails various formulation levels. The symptoms have to be differentiated from other definite disorders such as illusions and hallucinations. The symptoms of metamorphopsia then have to be identified and the underlying disorder distinguished from other possible diagnoses. The symptoms also need to be clarified whether they are the reason or part of the diagnosis. Previously AIWS was majorly confused with other childhood disorders such as migraine and depression. After the right treatment AIWS such as pharmacological treatment aimed at relieving the underlying conditions, the patient reverts to normal. Anti-psychosis medications can also be used to lower epileptic activity (Marino et al. 2010). Other drugs such as antidepressants and anti-viral are also vital in treating AIWS.
Controversies Surrounding AIWS
Due to the unusual nature of AIWS epidemiology data on large populations is unavailable. Clinical studies, however, indicate that the condition affects females more than male. Others have emphasized that there is no sex predilection except associated migraine cases. In such cases, migraines are identified to be prevalent in females.
Additionally, the onset of symptoms and multiple occurrences is also controversial. Statistical trends of the syndrome suggest the possibility of more than two symptoms coinciding (Blom, 2016). However, other research emphasizes that the occurrence of other symptoms is just before or after the onset of migraine episodes (Marino et al. 2010).
The issue of whether distorted visual input could directly influence the computational perception of hand size in such a manner that it affects manual motor control is affected highly controversial. Despite being an influential part of AIWS, this issue has been rejected by multiple scholars such as Algioti et al. 1995 who believed that such perceptual systems could not influence motor responses (Marino et al. 2010). In a more recent report, Kammers et al. 2009 also pointed out that rubber hand illusions do not influence the motor system (Marino et al. 2010). Using maximum grip aperture (MGA) Marino et al. (2010) discovered that distorted visual perceptions of art or the whole body affected the response time and efficacy of specific mortar responses. However, such responses also depended on the type of activity and the frequency with which an individual does similar activities daily. Frequently done motor responses depended less on spatial perspective. Therefore, limited visual distortion had limited impact.
Theoretical Conceptualization of AIWS
Psychoanalysis by Sigmund Freud aims at understanding human behavior as well as informing an approach to therapy. Freud developed revolutionary ideas regarding the human psyche such as the distinction between the unconscious and conscious mind and the existing instinctual drives, transference, defenses, and resistance which helps in the understanding of the inner world (Lenzenweger & Clarkin, 2005). Personality disorders linked to AIWS such as depression and anxiety disorders have well-structured characteristics such as crying crises, loss of sleep and pleasure resulting in hallucinations manifested through psychosis. The conception of treating AIWS through therapy follows Freud's as it aims in understanding human behavior as a fundamental step in alter...
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