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To see or not to see: A brief look at hallucinations in virtual reality applications

As a teenager I was fascinated with LSD purely as a consequence of my love of The Beatles and its alleged association with songs such as ‘Lucy in the Sky with Diamonds‘ (I say ‘alleged’ because all Beatle fanatics know that this song got its’ title from a drawing by John Lennon’s son Julian and that lyrically the song was inspired by the writings of Lewis Carroll, the creator of Alice in Wonderland [AIW], a book which gave its’ name to AIW Syndrome that I examined in a couple of previous blogs).

When I first started teaching my ‘Addictive Behaviours’ module back in 1990, almost all my lectures concentrated on drug addictions (as opposed to behavioural addictions which now take centre stage in my teaching), and it was my session on hallucinogenic drugs (also known as psychedelic drugs) that was always the most fun to teach and the topic that students appeared to be most engaged in. Like many of my students, I have always been interested in altered states of consciousness both in my own research into addiction and the topic more generally.

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The reason why I mention all these things as that I did a media interview on the hallucinogenic effects of virtual reality products. The interview was based on comments by Microsoft researcher Mar Gonzalez Franco, who said that virtual reality will soon replace the need for hallucinogenic drugs. More specifically, she was quoted as saying:

“By 2027 we will have ubiquitous virtual reality systems that will provide such rich multi-sensorial experiences that will be capable of producing hallucinations which blend or alter perceived reality. Using this technology, humans will retrain, recalibrate and improve their perceptual systems…In contrast to current virtual reality systems that only stimulate visual and auditory senses, in the future the experience will expand to other sensory modalities including tactile with haptic devices“.

Claims that VR products have the potential to induce hallucinogenic experiences have already started appearing in the media. A recent story in the Daily Mail reported that there was already a VR app (SelfSound) that claimed it can reproduce the effects of hallucinogenic drugs and plays on the neurological phenomena known as synaesthesia and that a “program is used to promote mediation through creating abstract reality [and] plays face-melting music with synesthetic DMT-style visualizations uniquely generated in response to [a person’s] voice”. (DMT is an abbreviation for dimethyltryptamine, a powerful hallucinogenic drug).

Over the last seven years, I have published a series of studies with Dr. Angelica Ortiz de Gotari (some of them listed in the ‘Further reading’ section below) showing that hallucinations are common among video gamers in our working examining Game Transfer Phenomena (GTP). Therefore, it’s no surprise that VR games can do the same thing. We have reported that visual and auditory hallucinations are commonly experiences by regular videogame players.

For instance, one of our studies published in the International Journal of Human-Computer Interaction found that some video gamers experience altered visual perceptions after playing (e.g., distorted versions of real world surroundings). Others saw video game images and misinterpreted real life objects after they had stopped playing. Gamers reported seeing video game menus popping up in front their eyes when they were in a conversation, or saw coloured images and ‘heads up’ displays when driving on the motorway. Our study analysed 656 experiences from 483 gamers collected in 54 online video game forums. Visual illusions can easily trick the brain, and staring at visual stimuli can cause ‘after-images’ or ‘ghost images’ among videogame players. We found that GTP were triggered by associations between video game experiences, and objects and activities in real life contexts. Our findings also raised questions about the effects of the exposure to specific visual effects used in video games.

We also reported that in some playing experiences, video game images appeared without awareness and control of the gamers, and in some cases, the images were uncomfortable, especially when gamers could not sleep or concentrate on something else. These experiences also resulted in irrational thoughts such as gamers questioning their own mental health, getting embarrassed or performing impulsive behaviours in social contexts. However, other gamers clearly thought that these experiences were fun and some even tried to induce them.

Visual experiences identified in GTP show us the interplay of physiological, perceptual and cognitive mechanisms and the potential of learning with video games even without awareness. It also invites us to reflect about the effects of prolonged exposure to synthetic stimuli and the challenges that the human mind affront due to the technological advances that are still to come. However, because we collected our data for most of our published studies from online video game forums, the psychological profile of the gamers in our studies are unknown. However, different gamers reported similar experiences in the same games. This highlights the relevance of the video games’ structural characteristics but gamers’ habits also appear to be crucial. Some gamers may be more susceptible than others to experience GTP. The effects of these experiences appear to be short-lived, but some gamers experience them recurrently. It goes without saying (but I’ll say it anyway) that more research is needed to understand the cognitive and psychological implications of GTP. Most of these GTP experiences are viewed positively but a small minority of players find them detrimental.

Whether such hallucinations – either in typical videogames or VR videogames – can be induced on demand is debatable. Very few players in our own research said they were able to induce hallucinations. At present, we simply don’t know what the long-term effects of VR gaming will be and that goes for VR-induced gaming hallucinations too. It may be the case that VR induced hallucinogenic states will be ‘safer’ than ones induced by psychedelic drugs as there is no ingestion of a psychoactive substance, but that’s just speculation on my part.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Cawley, C. (2016). Virtual Reality could make you hallucinate; Don’t freak out. Tech Co, December 15. Located at: http://tech.co/virtual-reality-hallucinate-dont-freak-2016-12

Hamill, J. (2016). Windows of perception: Microsoft says virtual reality will soon have same mind-bending effects as LSD. The Sun, December 7. Located at: https://www.thesun.co.uk/news/2347705/microsoft-says-virtual-reality-will-soon-have-same-mind-bending-effects-as-lsd/

Liberatore, S. (2016). That’s trippy! Watch the VR app that claims to be able to reproduce the effects of a hallucinogenic drug. Daily Mail, May 4, Located at: http://www.dailymail.co.uk/sciencetech/article-3572184/That-s-trippy-Watch-VR-app-claims-able-reproduce-effects-hallucinogenic-drug.html

Ortiz de Gortari, A.B. & Griffiths, M.D. (2012). An introduction to Game Transfer Phenomena in video game playing. In J. Gackenbach (Ed.), Video Game Play and Consciousness (pp.223-250). Hauppauge, NY: Nova Science.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Altered visual perception in Game Transfer Phenomena: An empirical self-report study. International Journal of Human-Computer Interaction, 30, 95-105.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. International Journal of Cyber Behavior, Psychology and Learning, 4(1), 59-75.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Automatic mental processes, automatic actions and behaviours in Game Transfer Phenomena: An empirical self-report study using online forum data. International Journal of Mental Health and Addiction, 12, 432-452.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2015). Game Transfer Phenomena and its associated factors: An exploratory empirical online survey study. Computers in Human Behavior, 51, 195-202.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2015). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. In: Gamification: Concepts, Methodologies, Tools, and Applications (pp.1329-1345). Pennsylvania: IGI Global.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2016). Prevalence and characteristics of Game Transfer Phenomena: A descriptive survey study. International Journal of Human-Computer Interaction, 32, 470-480.

Ortiz de Gortari, A.B., Pontes, H.M. & Griffiths, M.D. (2015). The Game Transfer Phenomena Scale: An instrument for investigating the non-volitional effects of video game playing. Cyberpsychology, Behavior and Social Networking, 18, 588-594.

Rothman, P. (2014). Virtual Reality and Drugs – Yes, you should get high before using VR. H Plus Magazine, July 31. Located at: http://hplusmagazine.com/2014/07/31/virtual-reality-and-drugs-yes-you-should-get-high-before-using-vr/

One giant step for man: Another look at macrophilia

Earlier this week, an article by Felicity Monk was published on the Broadly website about macrophilia (individuals derive sexual arousal from a fascination with giants and/or a sexual fantasy involving giants) and also known as giant (or giantess) fetishism. Broadly is an offshoot of Vice.com and is a website is a website “devoted to representing the multiplicity of women’s experiences”. I have been interviewed by both Broadly and Vice over the last few years on a number of topics including gambling, dacryphilia, and Alice in Wonderland Syndrome. I was interviewed for the Broadly article mainly because I’m one of the few academics ever to have written an article on the topic. I was quoted as saying in the Broadly article that “no-one has ever published even so much as an interview with a macrophile in an academic journal”.

In the Broadly article, Monk managed to interview a couple of macrophiles including Katelyn, a bisexual female in her thirties (five foot two inches tall) who has a number of co-occurring fetishes including macrophilia (in which she is sexually aroused by the thought of being a giant). She also has her own giantess website (which can be accessed here, but please be warned that the site features sexually explicit content) which she set up so that macrophiles could come and “worship” her. For Katelin, her macrophilic tendencies started from watching Tom and Jerry cartoons and the disparate size of the characters. As Katelyn said:

“The first time I had a good tingly feeling was when I was watching Tom have so much fun trying to catch Jerry. I always liked how Jerry got away so that the game would continue. I so badly wanted to be that cat. Little did I know it was the start of my sexuality. [By the time I got to high school I] was fantasising about literally crushing [my] high school crushes, swallowing [my] boyfriends and girlfriends alive, and putting [my] entire foot through the school. Most of the time I felt out of place and very alone sexually. [My preferred size of being a giant] changes depending on what mood [I’m] in. Some days I’m in the mood to play with the entire earth/galaxy, and other times I’m in the mood to attack a lone city as a 100ft woman. I rarely go below 100 feet. Most commonly, however, I’m fantasizing about being mega – 3000-plus feet tall”.

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Katelyn has now monetized her fetish by turning her website into a commercial venture. As the article in Broadly notes:

“[On Katelyn’s website you] will find videos for sale – many of which feature miniature, plastic people being swallowed or crushed under huge feet. There are also stories, comics, photographs, collages, a blog, and a link to Katelyn’s Amazon wish list, so her worshippers can purchase her gifts: underwear, Starbucks gift cards, vitamins so she can ‘grow’ bigger, and non-stick saucepans. Visiting the site is free, but each month around 700 of her fans make a purchase”.

My own research into macrophilia suggests that the overwhelming majority of macrophiles appear to be heterosexual males that are sexually attracted to female giantesses. However, I’ve also noted that even non-sexual scenarios involving giants can result in sexual stimulation. Each fantasy situation is different for every macrophile as the behaviour is fantasy-based. Even the preferred heights of the fantasy giants differ between individuals. For instance, some macrophiles have a preference for people only a few feet taller than themselves, whereas others involve giants who are hundreds of feet high.

In the Broadly article, Katelyn admitted she had other sexual fetishes including an “extreme mouth fetish” of similar intensity to her giantess fetish as well as furry and hentai fetishes (anime and manga pornography). This concurs with what I noted in my previous blog on macrophilia where I said that it had also been associated with other sexual paraphilias. I claimed the most noteworthy were:

  • Breast fetishism: This is a sexual fetish in which an individual derives sexual arousal from being pressed against, or placed in between, the breasts of a giant woman.
  • Dominance/submission: This is a sexual fetish in which an individual derives sexual pleasure being at the mercy of a giant, or from being in control of a tiny person.
  • Sadism/masochism: This is a sexual paraphilia in which an individual derives sexual pleasure from being physically harmed or even killed (in this case by a giant).
  • Vorarephilia: This is a sexual paraphilia in which individuals derive sexual arousal from the idea of being eaten, eating another person, or observing this process. Although there are cases of real life vorarephilia (that I wrote about in a previous blog), the behaviour is typically fantasy-based (e.g., fictional stories, fantasy art, fantasy videos, and bespoke video games).
  • Zoophilia: This is a sexual paraphilia in which individuals derive sexual pleasure from sex with animals (in this case, the desire is to have sex with a giant animal that is given human characteristics (i.e., anthropomorphism). This also has some crossover with furries (those individuals who – amongst other behaviours – like to dress as animals when having sex)
  • Crush fetishism: This is a sexual fetish in which an individual derives sexual arousal from being stepped or sat on by a giant person, and is also a variant of sexual masochism.

When Monk interviewed me, one of the most important questions she wanted an answer for was how people develop macrophilic tendencies. I told her that the roots of most fetishes lie in childhood and early adolescence where sexual arousal is, at first, accidentally associated with giants – maybe watching a TV programme where a giantess initiates feelings of sexual arousal. Over time the giant itself is enough to cause sexual arousal through classical conditioning. However, as there are no case studies in the literature, this is complete speculation on my part. However, she also interviewed one of Katelyn’s ‘worshippers’ (‘Mark’) who appeared to confirm my speculative thoughts.

“[I remember] seeing a re-run of Attack of the 50 Foot Woman when [I] was around 13 years old. The [point of view] of Allison Hayes walking across the desert was the first time I can recall being turned on. Seeing her tear the roof off of the building to get at her husband overwhelmed my young brain at the time. Shortly after that, another movie called Village of the Giants did the same thing. I can remember one of the giantesses in the movie said something like ‘Oh, why don’t I just step on him?’ which again turned my underage mind on like nothing prior. I would be uncontrollably drawn to [the giantess’] beauty and power despite the danger such an encounter would bring. As a superior being, she would have little regard for me other than supplying her own needs. Whether it be as food to nourish her superior body, or as a sexual play toy to be used and broken after, I would have no other choice other than submit myself to her. To have my life be hers to do with as she pleased would become the sole purpose for my existence. The exhilaration, danger, fear and sexual excitement would outweigh my very instinct for survival. I only wish it would become real”.

For her article, Monk also interviewed the Australian sex and relationship therapist Pamela Supple. Supple claimed that:

“Power, domination and vulnerability are at the heart of macrophilia. It’s allowing your mind to go wherever it wants to go, whilst engaging in play to gain the maximum sexual arousal. Some want to feel and experience terror – being crushed or controlled. Everyone is different in what they want to experience.”

Both I and Supple agree that macrophilia has enjoyed a massive surge in popularity in the past few years, with both of us citing the crucial role of the internet in helping to both create and facilitate the fetish “and, in some cases, introducing the fetish to those who have been looking for a name for what they feel”. This was confirmed by another one of Katelyn’s worshippers (‘Semeraz’). As he explained:

“[I didn’t know macrophilia’ was a thing” until [I] discovered Katelyn’s website. Before then, remember being in fifth grade and playing a game where the teacher assigned team names of ‘predator’ and ‘prey’ and becoming excited when a girl taunted him saying: ‘We’re going to eat you!’ But I never thought of it as a sexual fetish until running into Katelyn’s site”.

Since writing my article on macrophilia over four years ago, the presence of maxcrophilia online appears to have grown. Katelyn claims that her website was very niche when she set it up a number of years ago:

“It only had a handful of websites and contributors, a lot of lurkers – fetishes were much more taboo a decade ago – the content production was scarce and I was the only girl who had come out of the closet with the giantess fetish. Members thought there was no way a girl could have the giantess fetish. That made me feel alone, because I was the only giantess, and a lot of people doubted my sexuality. Nowadays, there’s so much giantess fetish content that you wouldn’t be able to see everything in a lifetime. There are millions of collages, stories, artists, producers, models, videos, and more.”

I’m not sure there are “millions of collages, stories, artists, producers, models, videos” out there on the internet but macrophilia is probably a lot less rare than I thought a few years ago.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biles, J. (2004). I, insect, or Bataille and the crush freaks. Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, Phenomenological Psychology and the Arts, 7(1), 115-131.

Bowen, J. (1999). Urge: A giant fetish. Salon, May 22. Located at: http://www.salon.com/1999/05/22/macrophilia/

Gates, K. (2000). Deviant Desires: Incredibly Strange Sex. New York: RE/Search Publications.

Love, B. (1992). Encyclopedia of Unusual Sex Practices. Fort Lee, NJ: Barricade Books.

Monk, F. (2016). The men who want to have sex with actual giants. Broadly, October 26. Located at: https://broadly.vice.com/en_us/article/macrophilia-fetish-the-men-who-want-to-have-sex-with-actual-giants

Pearson, G.A. (1991). Insect fetish objects. Cultural Entomology Digest, 4, (November).

Ramses, S. (undated). Introduction to macrophilia. Located at: http://www.pridesites.com/fetish/mac4black/intro2macro.htm

Slothrop, T. (2012). The Bible and Macrophilia: He Thong’s Goliath Art. Remnant of Giants, February 6. Located at: https://remnantofgiants.wordpress.com/2012/02/06/the-bible-and-macrophilia-he-thongs-goliath-art/

Small talk: Alice in Wonderland Syndrome (Revisited)

Last week, I was contacted by the journalist Abigail Moss about a previous blog that I wrote on Alice in Wonderland Syndrome (AIWS). AIWS is a non-contagious disorientation disorder and refers to when a person’s sense of body image, vision, hearing, touch, space, and/or time are distorted. AIWS sufferers typically experience micropsia (a neurological condition that affects human visual perception in which objects are perceived to be smaller than they actually are and make people feel bigger than they are) or macropsia (a neurological condition that affects human visual perception in which objects are perceived to be larger than they actually are and makes people feel smaller than they actually are).

Moss suffers from AIWS herself and has described her experiences both on camera (for instance in a short YouTube news piece and in numerous news articles such as one in the Daily Mail). Moss also sent me a first-person account of AIWS that she published in the online magazine Planet Ivy. Here are some of the things she recounted:

Extract 1: “When I was about five years old, I started to experience strange visual and sensory hallucinations. My hands and legs would seem too big for my body and the room around me would start to shrink inwards. All movements and sounds would seem extremely fast and hugely exaggerated, giving everything an odd feeling of urgency. This would last about 20 minutes and slowly fade away, and happened about four or five times a week…Luckily, my dad knew exactly what I was describing…He’d experienced the same thing as a kid. I haven’t outgrown it…but it doesn’t happen as often – maybe only five times a year”.

The first doctor suggested she might have a form of epilepsy but after that proved negative she was never diagnosed with anything official. Since then, other medics have suggested that she may have a sleep disorder or some kind of schizophrenia. It wasn’t until she was in her early twenties that she came across something that fitted her symptoms:

Extract 2: “Last year a tiny 50-word inset in a newspaper supplement caught my eye. ‘Alice in Wonderland Syndrome’ the heading read, and underneath it, a perfect description of my experience…I joined a Yahoo forum for ‘AIWS sufferers’…Countless fellow sufferers got in contact, all describing the same thing. Their descriptions were remarkably unvaried and it was immediately obvious this was the same thing I experience: ‘My body felt minuscule’, ‘Sounds were amplified’, ‘Everything was bigger and smaller at the same time’.”

The article outlined the many psychiatrists and psychologists Moss had visited about her condition with all the experts she saw claiming that they had never heard of AIWS. While the condition is rare, the condition has been well documented in the medical and clinical literature (see ‘Further reading’ below) so I was quite surprised that the experts she visited couldn’t have at least spent some time reading up on the syndrome. She then went on to say:

Extract 3: “My brain does something extremely weird, and nobody – not even the world’s leading bodies in the study of brains – can tell me what this is or why it happens. For me, this isn’t a problem, I don’t want to get rid of my episodes – they’re an interesting talking point and everyone knows writers are basically quite boring people. The experience, when it does pop up, doesn’t actually bother me or affect my day-to-day life”.

Moss wanted to ask me a few questions about my understanding of AIWS and how much is now known about it. She knew this wasn’t my primary area of expertise, but said that any opinions I might be able to offer would be invaluable to the article she was writing. I told her that my article on AIWS was written in a journalistic capacity rather from any position of expertise but she still wanted me to answer a few questions. Moss asked me three questions and I thought I would use this blog to share my full answers with my readers.

Question 1: “In my research I’ve found it almost impossible to find solid answers about what causes AIWS. Can you offer a view on what makes this condition so difficult to pin down?”

AIWS has been reported in the psychiatric and psychological literature since the early 1950s. However, since the first papers in the topic less than 20 papers have ever been published and all of them are case reports. Finding ‘solid answers’ based on so few cases is therefore inevitable. The literature is also biased because it is (a) based on those sufferers who seek out medical assistance, and (b) based on those doctors or clinicians that have written the cases for publication. If people don’t seek help and/or there cases remain unwritten, there is little chance if finding ‘solid answers’.

Secondly, the symptoms are not always identical which is why it is referred to as syndrome (that is, a group of symptoms that together are characteristic of a specific disorder or disease, or a predictable, characteristic condition or pattern of behavior that tends to occur under certain circumstances). Syndromes typically have many different causes which again means it is difficult to find ‘solid answers’.

Finally, given that the experiences (like your own) are often short-lived, it is very rare to be able to monitor people neurologically. The few published cases are based on chronic sufferers (who may not be representative of the vast majority of AIWS sufferers). Several neurologists have done M.R.I.s on patients with the condition, though once the bout has passed, there’s usually no sign of unusual brain activity. I read that Dr. Sheena Aurora was the first to scan the brain of someone — a 12-year-old girl — in the middle of an episode. According to Dr. Aurora, electrical activity caused abnormal blood flow in the parts of the brain that control vision and process texture, shape and size.

The case studies that I have read have provided lots of possible reasons for AIWS but there is no consensus and they could all be true (as having the same symptoms doesn’t mean there has to be the same cause). Some research appears to indicate that AIWS can be due to abnormal amounts of electrical activity that causes blood to flow abnormally in the brain areas that process texture and visual perception. AIWS has been associated with migraines, severe depression, and (in extreme cases) brain tumours. Case study research has indicated that AIWS manifestations are due to disturbed function of either medial temporal, hippocampal, tempro-occipital or tempro-parieto-occipital regions of the brain. Unfortunately, chronic AIWS is untreatable and time is the only healer. However, sharing experiences with other sufferers is also thought to be therapeutically beneficial

Question 2: “Is academic disagreement just part and parcel of all psychological conditions or does AIWS seems particularly open to discussion?”

I don’t think there is ‘disagreement’ as no two clinicians or psychiatrists have ever published papers examining the same individuals. They have all published papers based on the AIWS sufferers that they themselves saw and that who came in seeking help. All of the explanations could be correct as syndromes have multiple causes. This is not disagreement. It’s simply a case of multiple possible causes.

Question 3: “I have spoken to a large number of people who also say they also experience AIWS – how useful or valid do you think it would be to think of AIWS as more of a mental phenomenon than a syndrome, comparable with something like déjà vu, for example?”

The word ‘large’ is what we psychologists call a ‘fuzzy quantifier’ as ‘large’ to one individual is small to another. If you have spoken to 100 other sufferers worldwide I would say this is very very small. The condition appears to be rare although in one of my other areas of research, we have demonstrated that a small proportion of video gamers experience disorienting visual effects (that we call game transfer phenomena) like AIWS so such phenomena may be multi-faceted and may arise from specific activities (such as excessive and immersive game playing).

AIWS should not be compared with déjà vu as most scientific evidence suggests that déjà vu is an anomaly of memory and totally different from AIWS on a neurological level (but I’m not an expert on déjà vu and am only basing my opinion on what I have read in the psychological literature). However, there may be some conditions (such as schizophrenia and temporal lobe epilepsy) where individuals may experience both AIWS and déjà vu but these are symptoms of a specific medical disorder. Most individuals that have experienced déjà vu (as many as two-thirds of the population in some studies) and AIWS (very rare) do not have any underlying serious medical conditions.

I don’t know if any of my responses to Moss were of help either in relation to her own experiences or in writing her article but I was pleased with the observations I had made.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bui, E., Chatagner, A. & Schmitt, L. (2010). Alice in Wonderland Syndrome in major depressive disorder. Journal of Neuropsychiatry and Clinical Neurosciences, 22, 352.e16-352.e16.

Cinbis, M. & Aysun, S. (1992). Alice in Wonderland syndrome as an initial manifestation of Epstein-Barr virus infection (case report). British Journal of Ophthalmology, 76, 316.

Eshel, G.M., Eyov, A., & Lahat, E., et al (1987). Alice in Wonderland syndrome, a manifestation of acute Epstein-Barr virus infection (brief report). Pediatric Infectious Diseases Journal, 6, 68.

Kew, J., Wright, A., & Halligan, P.W. (1998). Somesthetic aura: The experience of “Alice in Wonderland”. The Lancet, 351, 1934.

Kitchener, N. (2004). Alice in Wonderland Syndrome. International Journal of Child Neuropsychiatry, 1, 107-112.

Kuo, Y, Chiu, N.C., Shen, E.Y., Ho, C.S., Wu, M.C. (1998). Cerebral perfusion in children with “Alice in Wonderland” syndrome. Pediatric Neurology, 19, 105-108.

Lahat, E., Eshel, G., & Arlazoroff A (1990). “Alice in Wonderland” syndrome and infectious mononucleosis in children (letter). Journal of Neurology, Neurosurgery and Psychiatry, 53, 1104.

Lambert, M.V., Sierra, M., Phillips, M.L. & David, A.S. The spectrum of organic depersonalization: A review plus four new cases. Journal of Neuropsychiatry and Clinical Neuroscience, 14, 141-154.

Podoll, K., Ebel, H., Robinson, D., & Nicola, U. (2002). Obligatory and facultative symptoms of the Alice in wonderland syndrome. Minerva Medicine, 93, 287-293.

Podoll, K. & Robinson, D. (1999). Lewis Carroll’s migraine experiences. The Lancet, 353, 1366.

Rolak, L.A. (1991). Literary neurologic syndromes. Alice in Wonderland. Archives of Neurology, 48, 649–651.

Todd, J. (1955). The syndrome of Alice in Wonderland. Canadian Medical Association Journal, 73, 701–704.

Small claims caught: A beginner’s guide to Alice in Wonderland Syndrome

While researching a blog on Cotard Syndrome I came across a case study of Alice in Wonderland Syndrome published by Dr. Eric Bui and his colleagues published in the Journal of Neuropsychiatry and Clinical Neurosciences. They wrote:

“A 74-year-old retired French executive was admitted to hospital for major depressive disorder with psychotic features triggered by prostate surgery 3 months previously…The patient was described by his wife as usually sociable, jolly, scrupulous and a perfectionist. On admission, the patient presented with a depressed mood, loss of pleasure and interest, disordered sleeping, severe fatigue, loss of appetite, psychomotor retardation, and persecutory (being broken into and burgled) as well as somatic (his stools being contaminated) delusions…Ten days after admission, the patient exhibited new delusional symptoms: he believed his hands and feet were shorter than usual and was convinced that his clothes had shrunk. Organic causes (intracranial tumor and infection, thyroid disease, and nutritional deficiency) were ruled out by physiological, laboratory, neurological, and ophthalmological investigations…The patient continued to be delusional and severely depressed…He was discharged on day 45 of hospitalization with complete remission”.

As can be probably be surmised from this brief case study, Alice in Wonderland Syndrome (AIWS) is a non-contagious disorientation disorder and refers to when a person’s sense of body image, vision, hearing, touch, space, and/or time are distorted. AIWS sufferers typically experience micropsia (a neurological condition that affects human visual perception in which objects are perceived to be smaller than they actually are and make people feel bigger than they are) or macropsia (a neurological condition that affects human visual perception in which objects are perceived to be larger than they actually are and makes people feel smaller than they actually are). They may also experience feelings of paranoia.

AIWS has nothing to do with a malfunctioning of the eyes, but is a change in how the world is perceived with those suffering seeing objects the wrong shape or size. Arguably the most disturbing symptom for sufferers is the perceived alteration of their body image. AIWS sufferers become confused about the size and shape of their body (or specific body parts). Time perception may also be affected with many sufferers reporting that time seems to pass incredibly slowly as if they were on an LSD trip. Sufferers (most commonly thought to be children and migraine sufferers) often become very frightened, scared and panic-stricken, although it can often be treated successfully through complete rest and relaxation (and in most cases is a relatively temporary condition). Some research appears to indicate that AIWS can be due to abnormal amounts of electrical activity that causes blood to flow abnormally in the brain areas that process texture and visual perception.

AIWS was named after the 1865 book Alice’s Adventures in Wonderland by Lewis Carroll, but is also known as Todd Syndrome named after the psychiatrist who first wrote about the condition in a 1955 issue of the Canadian Medical Association Journal. (Interestingly, a short article by Dr. Klaus Podoll and Dr. Derek Robinson in The Lancet from 1999 highlighted that Carroll was a migraine sufferer and that his book may have been inspired by his own personal experiences!). Todd’s original paper reported five patients (of which four were female) all of who suffered from severe migraines. All of these patients described their body, body parts and/or objects around them changing in size (with two of them also having time disorientation too). On the basis of these five cases, Todd coined the term ‘Alice in Wonderland Syndrome’ (although such hallucinations had been noted three years prior to this by Dr. C.W. Lippman in a 1952 paper on certain hallucinations peculiar to migraine”).

The condition has also been associated with other medical conditions besides migraines, including (mononucleosis) infections, and severe depression, and (in extreme cases) brain tumours. A paper by Dr. Nabil Kitchener in a 2004 issue of the International Journal of Child Neuropsychiatry also noted that AIWS can also be the presenting manifestations in some patients with epilepsy, hyperpyrexia (i.e., extremely elevated body temperatures), typhoid encephalopathy, and other psychiatric disorders. In a 2005 paper in the journal European Neurology, Dr. Valmantas Budrys also reported that AWS could occur in hypnagogic, delirious states, encephalitis, cerebral lesions, drug intoxication, and schizophrenia.

In a literature review on organic depersonalization in the Journal of Neuropsychiatry and Clinical Neuroscience, Dr. Michelle Lambert and her colleagues examined the literature on AIWS. The noted that since Todd’s case studies were published, the subsequent published case reports of body image distortion associated with AIWS, often included depersonalization and/or derealization. They suggested that such symptom were consistent with parietal lobe pathology. More specifically, they argued that the frequent accompanying symptoms of fear, anxiety, and panic implicate the role of the temporal lobe. Dr. Kitchener’s 2004 paper also concludes that AIWS manifestations are due to disturbed function of either medial temporal, hippocampal, tempro-occipital or tempro-parieto-occipital regions of the brain based on the research of Dr. Kuo and colleagues published in a 1998 study in the Pediatric Neurology journal.

However, the case study published by Dr. Bui and his colleagues that I began this blog suggested that AIWS may be similar to Cotard Syndrome (CS). As the authors noted, that:

“Cotard Syndrome comprises any one of a series of delusions ranging from the belief that one has lost organs to the conviction that one is dead. Since Cotard’s syndrome is also usually associated with severe depression and improves rapidly with ECT [electro-convulsive therapy], it is possible that the somatic delusions experienced by our [AIWS] patient were a variant of this syndrome. According to our observations, the psychotic features of major depressive disorder might present in the form of Alice in Wonderland syndrome although the relationship between this syndrome and Cotard’s syndrome remains to be determined”.

Depending upon co-morbid conditions, medical treatments include beta blockers, anti-depressants, and anti-convulsants, AIWS has also been reported in both the Pediatric Infectious Diseases Journal (1987) and British Journal of Ophthalmology (1992) as one of the early signs of the Epstein-Barr Virus, one of the most common human viruses and of the herpes family. Most commonly it causes glandular fever but is associated with various forms of cancer including Hodgkin’s lymphoma. Chronic AIWS is untreatable and time is the only healer. Sharing experiences with other sufferers is also thought to be therapeutically beneficial (although I know of no clinical support for the claim).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Budrys, V. (2005). Neurological eponyms derived from literature and visual art. European Neurology, 53, 171-178.

Bui, E., Chatagner, A. & Schmitt, L. (2010). Alice in Wonderland Syndrome in major depressive disorder. Journal of Neuropsychiatry and Clinical Neurosciences, 22, 352.e16-352.e16.

Cinbis, M. & Aysun, S. (1992). Alice in Wonderland syndrome as an initial manifestation of Epstein-Barr virus infection (case report). British Journal of Ophthalmology, 76, 316.

Eshel, G.M., Eyov, A., & Lahat, E., et al (1987). Alice in Wonderland syndrome, a manifestation of acute Epstein-Barr virus infection (brief report). Pediatric Infectious Diseases Journal, 6, 68.

Kew, J., Wright, A., & Halligan, P.W. (1998). Somesthetic aura: The experience of “Alice in Wonderland”. The Lancet, 351, 1934.

Kitchener, N. (2004). Alice in Wonderland Syndrome. International Journal of Child Neuropsychiatry, 1, 107-112.

Kuo, Y, Chiu, N.C., Shen, E.Y., Ho, C.S., Wu, M.C. (1998). Cerebral perfusion in children with “Alice in Wonderland” syndrome. Pediatric Neurology, 19, 105-108.

Lahat, E., Eshel, G., & Arlazoroff A (1990). “Alice in Wonderland” syndrome and infectious mononucleosis in children (letter). Journal of Neurology, Neurosurgery and Psychiatry, 53, 1104.

Lambert, M.V., Sierra, M., Phillips, M.L. & David, A.S. The spectrum of organic depersonalization: A review plus four new cases. Journal of Neuropsychiatry and Clinical Neuroscience, 14, 141-154.

Lippman, C.W. (1952). Certain hallucinations peculiar to migraine. Journal of Nervous and Mental Diseases, 116, 346-351.

Podoll, K., Ebel, H., Robinson, D., & Nicola, U. (2002). Obligatory and facultative symptoms of the Alice in wonderland syndrome. Minerva Medicine, 93, 287-293.

Podoll, K. & Robinson, D. (1999). Lewis Carroll’s migraine experiences. The Lancet, 353, 1366.

Rolak, L.A. (1991). Literary neurologic syndromes. Alice in Wonderland. Archives of Neurology, 48, 649–651.

Todd, J. (1955). The syndrome of Alice in Wonderland. Canadian Medical Association Journal, 73, 701–704.