Australian & New Zealand Journal of Psychiatry 1 © The Royal Australian and New Zealand College of Psychiatrists 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav journals.sagepub.com/home/anp Australian & New Zealand Journal of Psychiatry, 00(0) Alice in Wonderland Syndrome: An imitator of psychosis and other medical conditions Joel King 1,2 , Fiona Leow 3 , Sonja Cabarkapa 4 and Chee Ng 1,2 1 Professorial Unit, The Melbourne Clinic, Richmond, VIC, Australia 2 Department of Psychiatry, The University of Melbourne, Richmond, VIC, Australia 3 Eating Disorders Unit, The Royal Melbourne Hospital, Parkville, VIC, Australia 4 St Vincent’s Hospital, Melbourne, Fitzroy, VIC, Australia Corresponding author: Joel King, Professorial Unit, The Melbourne Clinic, 130 Church St, Richmond, VIC 3121, Australia. Email: jaking@unimelb.edu.au DOI: 10.1177/0004867418763528 To the Editor Alice in Wonderland Syndrome (AIWS) is a disturbance of perception leading to distortions of body, time and space.We present a 20-year-old man with a his- tory of infrequent migraines since child- hood. His general practitioner (GP) referred him for management of a first moderately severe depressive episode of 2 months duration, with no psychiat- ric history. He responded well to dulox- etine 60 mg daily. During follow-up, the patient described having intermittent micropsia and macropsia, lasting up to 30 minutes. These began at age 5 and frightened him as a child, until he real- ised they were not real. Both percep- tual disturbances and migraines diminished with age in frequency and intensity. They now occurred every 3 months and did not impair psychoso- cial function. However, he remained puzzled about his symptoms and wor- ried about its significance. Mental state examination revealed excellent insight and an absence of thought disorder, hal- lucinations and delusions. Neurological examination was unremarkable. Investigations to exclude causes of AIWS including full blood examination, electrolytes, liver function, vitamin B12, folate and thyroid function were unre- markable. Epstein–Barr virus (EBV) serology, Influenza H1N1 antibodies and Borrelia burgdorferi antibodies were negative. Electroencephalogram and magnetic resonance imaging (MRI) of the brain were unremarkable. The patient was reassured when education about AIWS and relationship to migraines was provided. First described in 1955, AIWS is a rare disorder with 169 cases described in the literature (Blom, 2016). The car- dinal symptoms are alterations in body size perception, with head and hands often seeming disproportionate. Per- ceptual disturbances can also occur in relation to objects, time and distance. Stationary objects may appear to move (kinetopsia) and straight lines may appear wavy (dysmorphopsia). Unlike hallucinations, AIWS involves percep- tual distortions of actual stimuli. Sym- ptoms usually occur at night. AIWS is associated with migraines, temporal lobe epilepsy, brain tumours, EBV and psychoactive drugs. Sensory integration dysfunction in the tempo- roparietal-occipital carrefour has been postulated as causative (Mastria et al., 2016). AIWS has no proven treatment. Most cases spontaneously remit or vary in outcome depending on the underlying condition. Treatment usu- ally involves reassurance and manage- ment of underlying conditions. AIWS can be distinguished from schizophrenia on the characteristic nature of perceptual disturbances, absence of thought disorder and delu- sions, good insight and age of onset usually in childhood (Montastruc et al., 2012). This is important in pro- viding patients an accurate diagnosis, prognosis, reassurance and avoiding antipsychotics, which are ineffective. Finally, investigations can be initiated by the psychiatrist to exclude medical causes of AIWS. Declaration of Conflicting Interests The author(s) declared no potential con- flicts of interest with respect to the research, authorship and/or publication of this article. Funding The author(s) received no financial sup- port for the research, authorship and/or publication of this article. References Blom JD (2016) Alice in Wonderland Syndrome: A systematic review. Neurology: Clinical Practice 6: 259–270. Mastria G, Mancini V, Viganò A, et al. (2016) Alice in Wonderland Syndrome: A clinical pathophysiological review. BioMed Research International 2016: 8243145. Montastruc F, Schwarz N, Schmitt L, et al. (2012) An overview of the symptoms and typical dis- orders associated with Alice in Wonderland Syndrome. Neuropsychiatry 2: 281–289. Letter 763528ANP 0 0 10.1177/0004867418763528ANZJP CorrespondenceANZJP Correspondence research-article 2018 Letter