Alice in Wonderland Syndrome

Alice in Wonderland Syndrome (AIWS) is a neuropsychological disorder with no more than 200 reported cases worldwide. (a)It was characterized by distortions of perception, particularly involving somesthetic and visual integration with unknown causes. The patient is experiencing the size distortion including micropsia or macropsia, pelopsia or teleopsia, the experience of time and the body schema. (b)In the past, there are only a few reports that associated AIWS with a depressive disorder with inadequate evidence proved. Therefore, to enhance 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.

A 65-year-old Chinese woman with neither has a psychiatric and medical history before. Stated by her husband, she was an outgoing, sociable and hardworking person and has a steady job since university graduation until 60.

A half-year before her first admission to the psychiatric unit, her husband found out that her personality was changed that she turned emotional and always complained of everything. One month before the first admission, she started complaining about AIWS symptoms, including the altered perception of her body image and macropsia. From her sights, all objects including cars and house turned extraordinary huge to her. Furthermore, she felt her body was significantly thinner than normal. Sometimes, she felt as if she could walk within 30 minutes from her hometown Shenzhen to Shanghai which is impossible in reality. She was diagnosed with severe depression with AIWS and being hospitalized for the first time. With the administration of perphenazine and amitriptyline, no symptoms of AIWS were found and she was completely recovered from it.

After 2 years, she had the depression recurrence with significant AIWS symptoms. Apart from the symptoms having in the last episode, she could not appreciate the value of money and sense the importance of the news and express the appropriate feelings. Other than that, she was unable to sense the urge to urinate and excreted out even though having a normal excretory function. Despite the administration of aripiprazole and amitriptyline inward, the condition even gets worsen. Thus, a comprehensive check-up was performed and none of the potential causes and organ abnormalities shown such as dementia except having severe depression. She recovered completely from AIWS and almost fully from the depressive episode after receiving the administration of mirtazapine, duloxetine and twice-weekly ECT.

Although the etiology of AIWS is unclear without any accepted diagnostic criteria now, there are some possible factors and conditions associated with it as proved in some cases. The major causes of AIWS are migraines and infections which mainly linked to Epstein-Barr virus while the minor is drugs, brain injuries and epilepsy. (d)However, there are only a few research about the linkage between psychiatric disorders and AIWS. In this case, there is some possible association between both of them. Therefore, a better understanding of AIWS could be reached and this would be a significant development of the disease.

In this case study, the patient presented with two major depressive episodes and the typical symptoms and characteristics of AIWS were also found. There were some published reports demonstrated that the relationship between AIWS and psychotic depression, but neither of which clearly showed AIWS and the concurrent nature of major depressive episodes. For the first case, (a)a 74-year-old man believed that his stools being contaminated which exhibited severe depressive symptoms with somatic delusions. Furthermore, he thought his hands and feet were shorter than usual which showed the symptoms of AIWS. And for another case, a 54-year-old man complained of some depressive symptoms with AIWS including distortion of body image and metamorphopsia. More importantly, it is discovered that the former developed somatic delusions while the latter presented a delusion of culpability. This is in line with the patient in this case since she has a delusion that she was very poor. Therefore, it demonstrated that there are several symptoms of AIWS in the patient diagnosed with psychotic depression.

Other than that, 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. The patient may hear and see things that don’t exist. Besides, low mood, feelings of worthlessness also occurred on the patient. In this case, the patient felt fatigued and reluctant to attend social activities. Furthermore, she was unable to sense the magnitude of objects including the difficulty in money and news which could be perceived as being part of the incapacity categories. The failure of feeling the need for excretion could be viewed by indifference. Given this, it indicated that the patient’s body, space and time were constricted which is a principle characteristic that same as the symptoms of AIWS. Regarding the three cases shown above, there is surely a close association between psychotic depression and AIWS.