Alice in Wonderland Syndrome - A Literature Review

Abstract

Introduction:
Alice in Wonderland syndrome (AIWS), also known as Todd’s syndrome, is a rare perceptual disorder characterized by disturbances in visual perception, body schema, and time experience. First described in 1955, it reflects phenomena similar to those depicted in Alice’s Adventures in Wonderland. Common symptoms include micropsia, macropsia, and altered perception of one’s own body, often accompanied by derealization and temporal distortion. AIWS is most frequently associated with migraine, infections, and epilepsy, and appears more common in children. Despite its characteristic clinical presentation, it remains underdiagnosed and lacks standardized diagnostic criteria.

Aim:
The aim of this narrative review is to summarize current knowledge on AIWS based on literature published between 2015 and 2026, with reference to earlier key studies on diagnostic criteria. The paper focuses on clinical features, pathophysiology, and associated conditions, while identifying gaps for future research.

Materials and Methods:
A literature search was conducted using PubMed, Scopus, Web of Science, ResearchGate, and Google Scholar. Keywords included “AIWS,” “micropsia,” “macropsia,” “migraine,” and “AIWS neuroimaging.” Studies from 2015–2026 were prioritized, along with a key 2013 study on diagnostic criteria. Both clinical and neurobiological data were analyzed.

Conclusion:
AIWS is a heterogeneous condition likely resulting from dysfunction of distributed brain networks responsible for multisensory integration rather than focal lesions. Various etiologies, including migraine, infections, and epilepsy, appear to converge on common neural pathways. Treatment should target the underlying disorder, often leading to symptom improvement. However, lack of clear diagnostic criteria contributes to underrecognition. Further research, particularly using advanced neuroimaging, is needed to better understand its mechanisms and improve diagnosis.