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Imagine, as you’re getting up from the dinner table, as you blink, you look down and notice that the apple on your plate is suddenly enormous, the size of a tortoise. When you rise from your chair, you feel your legs are three times longer than normal—as though you were dangling on stilts above the table and the now monstrous fruit. If this happened to you, you might begin to suspect that you had slipped down the rabbit hole into Lewis Carroll’s Wonderland along with Alice.
Neurologist Maximilian Friedrich first heard this very anecdote from his great-grandmother when he began studying perception. She had experienced it decades earlier when she was a mother suffering from migraines, but it never happened again and she kept it a secret—there was too much stigma around illnesses of the mind at the time. Today, her great-grandson is a researcher at University Hospital Wuerzburg in Germany—and he studies what has become known as Alice in Wonderland syndrome.
“Their world really warps—it’s such an uncanny experience,” says Freidrich. Neurologists don’t understand the syndrome, and Friedrich wanted to change that.
It may be a lot more common than we think. Though just 200 individual cases have been reported since the 1950s, recent studies suggest that up to 20 percent of migraine patients may suffer from the syndrome, while evidence suggests that up to 30 percent of adolescents have experienced some of its symptoms. Some sufferers see figures with extra body parts, feel that walls are closing in, or it may sound to them as though other people are talking unnaturally fast or slow. The episodes usually pass in a matter of minutes, and no medical tests can so far diagnose these events.
Such perceptual distortions may have inspired Carroll, whose protagonist Alice, in his 1865 children’s book Alice’s Adventures in Wonderland, senses her own body growing larger and smaller in the fantasy world of Wonderland. (Carroll also reportedly suffered from migraines, but it’s not clear whether he experienced the syndrome itself.) English psychiatrist John Todd was the first to give the syndrome a name, almost a century later, in 1955. Today it is defined as a disorder involving perceptual distortions of size and scale, particularly of one’s own body, objects in the environment, or of time.
Some sufferers see figures with extra body parts, feel that walls are closing in.
A new study co-authored by Friedrich is one of the first attempts to shed light on neurological networks that may be associated with some of its symptoms. The researchers mapped certain circuits in the brains of 37 individuals who have experienced Alice in Wonderland syndrome. What they found may shed light not only on how it arises, says Friedrich, but on human perception more generally.
Friedrich’s great-grandmother had a migraine right after her experience, and migraine is considered the number one cause of the disorder’s symptoms. But migraine doesn’t leave the kind of trace that can be picked up by functional magnetic resonance imaging scans, which makes it difficult to research these patients.
Evidence suggests that lesions in the brain produced by a stroke or brain bleeding are the second most common cause of the syndrome. So Friedrich and his colleagues mapped the lesions found in 37 people who had experienced the syndrome and then examined existing fMRI data about which brain networks most commonly connect to the locations of the lesions. They found that over 85 percent of the lesion locations shared connections to two specific hubs in the brain: the right extrastriate body area, known to be involved in viewing body parts, and the inferior parietal cortex, known to be involved in judgments of scale and size. The research was published this summer in the journal Annals of Neurology.
“These are truly novel findings which I expect to have substantial implications for further research on Alice in Wonderland syndrome, and hopefully also for patient care,” says Jan Dirk Blom, a professor of clinical psychopathology at Leiden University who studies hallucinations and other perceptual phenomena. Most prior research consists of case studies, exploring the experiences of one patient at a time—this is the first study to examine the brains of a group of patients.
Friedrich points out that while he and his colleagues were successful at mapping brain networks that may be associated with the symptoms, they still want to understand exactly how these brain networks malfunction. For some patients, objects and bodies shrink—and for others, they enlarge.
A better understanding of Alice in Wonderland syndrome could demonstrate how perceptual disturbances lead to abnormal ideas about bodies more generally, Friedrich says, which has implications for understanding and treating anorexia or other body image disorders. There is some overlap in the brain areas that are overactive in people who have anorexia and Alice in Wonderland syndrome.
Friedrich says, “We should be a little cautious about our own perceptions and question our own perceptions, because sometimes they’re just not reality.” 
Lead art: HelloSSTK / Shutterstock
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