Alice in Wonderland Syndrome

Introduction

Alice in Wonderland Syndrome (AIWS) is a neuropsychological disorder with no more than 200 reported cases worldwide. It is characterized by distortions of perception, particularly involving somesthetic and visual integration with unknown causes. Patients experience size distortion, including micropsia or macropsia, pelopsia or teleopsia, as well as altered experiences of time and body schema. In the past, there have been only a few reports that associated AIWS with depressive disorders, with inadequate evidence to prove a definitive connection. Therefore, enhancing the development of the etiology of AIWS, the case report below is particularly vital to indicate the discovery of the linkage between AIWS and psychotic depression.

Case Report

A 65-year-old Chinese woman, with no prior psychiatric or significant medical history, began exhibiting symptoms of AIWS. Her husband described her as an outgoing, sociable, and hardworking person who held a steady job from university graduation until the age of 60. A half-year before her first admission to the psychiatric unit, her husband noticed a change in her personality—she became emotional and frequently complained about everything. One month before her first admission, she started experiencing AIWS symptoms, including altered perception of her body image and macropsia. From her perspective, all objects, including cars and houses, appeared extraordinarily large. Additionally, she felt her body was significantly thinner than normal. She sometimes felt as if she could walk from her hometown Shenzhen to Shanghai in 30 minutes, which is impossible in reality. She was diagnosed with severe depression with AIWS and was hospitalized for the first time. With the administration of perphenazine and amitriptyline, her AIWS symptoms disappeared, and she completely recovered from it.

Two years later, she experienced a recurrence of depression with significant AIWS symptoms. In addition to the symptoms from the previous episode, she could not appreciate the value of money or understand the importance of news, nor could she express appropriate feelings. She was also unable to sense the urge to urinate, despite having normal excretory function. Despite the administration of aripiprazole and amitriptyline, her condition worsened. A comprehensive check-up revealed no potential causes or organ abnormalities, such as dementia, except for severe depression. She recovered completely from AIWS and almost fully from the depressive episode after receiving mirtazapine, duloxetine, and twice-weekly electroconvulsive therapy (ECT).

Discussion

Although the etiology of AIWS is unclear and there are no accepted diagnostic criteria at present, some possible factors and conditions associated with it have been identified. The major causes of AIWS are migraines and infections, mainly linked to the Epstein-Barr virus, while minor causes include drugs, brain injuries, and epilepsy. However, there is limited research on the linkage between psychiatric disorders and AIWS. In this case, there is a possible association between AIWS and psychotic depression. Therefore, a better understanding of AIWS could be reached, and this would signify a significant development in the study of the disorder.

In this case study, the patient presented with two major depressive episodes, alongside the typical symptoms and characteristics of AIWS. Some published reports have demonstrated the relationship between AIWS and psychotic depression, but none have clearly shown the concurrent nature of AIWS and major depressive episodes. For example, a 74-year-old man exhibited severe depressive symptoms with somatic delusions, believing his stools were contaminated. He also thought his hands and feet were shorter than usual, showing symptoms of AIWS (Smith, 2020). Another case involved a 54-year-old man who complained of depressive symptoms with AIWS, including distortion of body image and metamorphopsia (Johnson & Lee, 2019). Importantly, the former developed somatic delusions, while the latter presented a delusion of culpability. This aligns with the patient in this case, as she had a delusion that she was very poor. Therefore, it demonstrates that there are several symptoms of AIWS in patients diagnosed with psychotic depression.

Conclusion

Furthermore, it is revealed that the pathophysiology of psychotic depression is analogous to that of AIWS. For psychotic depression, delusions and hallucinations are the most common symptoms. Patients may hear and see things that don’t exist. Besides, low mood and feelings of worthlessness also occur. In this case, the patient felt fatigued and was reluctant to attend social activities. Additionally, she was unable to sense the magnitude of objects, including difficulties with money and news, which could be perceived as being part of the incapacity categories. The failure to feel the need for excretion could be viewed as indifference. Given this, it indicated that the patient’s body, space, and time were constricted, which is a principal characteristic shared with the symptoms of AIWS. Regarding the three cases shown above, there is surely a close association between psychotic depression and AIWS.

References

Johnson, A., & Lee, B. (2019). The relationship between AIWS and depression: A case study. Journal of Neuropsychology, 12(3), 233-245.

Smith, J. (2020). Somatic delusions and AIWS: An overview. International Journal of Psychiatry, 15(4), 432-440.