Autometamorphopsy

A special case of metamorphopsia, concerning the disturbance of self-perception, that is, directly the size and shape of one's own body as a whole or its individual parts, is called autometamorphopsia. This pathology is not an independent disease and is considered within the framework of depersonalization syndrome as one of its manifestations. It develops with various disorders of the central nervous system.

Autometamorphopsia can be total, when the perception of one's entire body is distorted, or partial, when the distortions concern some part of the body. Western clinicians call this phenomenon Alice in Wonderland syndrome or Todd syndrome, after the British psychiatrist who coined the name.

Epidemiology

Autometamorphopsia is just a manifestation of a disorder of self-awareness in many diseases, so the exact statistics of the frequency of cases of this pathology are unknown. It is described in detail, so it is not uncommon. In children, it is impossible to diagnose with certainty such a disorder of the perception of one's own body. In adolescents, autometamorphopsia of purely stressful origin is also almost never encountered. Therefore, early manifestations of "body scheme disorder" are considered signs of serious diseases - schizophrenia, epilepsy or abuse of psychedelics. The debut of most cases of autometamorphopsia occurs before the age of 30, which generally coincides with the age of manifestation of the majority of cases of mental illness.

There are no epidemiological data on Alice in Wonderland syndrome in the general population. Although the syndrome is generally assumed to be rare, clinical studies among migraine patients suggest that the prevalence rate in this group may be around 15%. [ 1 ], [ 2 ] A cross-sectional study of 1480 adolescents [ 3 ] found a lifetime prevalence of micropsia and/or macropsia of 5.6% for males and 6.2% for females. A cross-sectional study [ 4 ] of 297 individuals with a mean age of 25.7 years found a lifetime prevalence of 30.3% for teleopsia, 18.5% for dysmorphopsia, 15.1% for macropsia, and 14.1% for micropsia.

Causes autometamorphoses

Unlike metamorphopsia, which can be a consequence of visual defects, isolated autometamorphopsia, which concerns only the distortion of the physical parameters of one's own body (other objects are perceived correctly), is a disorder of higher nervous activity and one of the manifestations of depersonalization syndrome, which is also extremely rare as an independent disease. Basically, a distorted perception of one's own body scheme is inherent in schizophrenics, epileptics, people suffering from migraines (during attacks), [ 5 ], [ 6 ], [ 7 ] anxiety, phobic, depressive, obsessive-compulsive disorder, organic lesions of cerebral structures (in acute disseminated encephalomyelitis) [ 8 ] and even vegetative-vascular dystonia (probably everyone has heard such an explanation for their malaise at least once in their life). The exact cause of the development of autometamorphopsia, as well as the diseases that cause this mental phenomenon, is under study. And it is certainly not the only one, since a disorder of the perception of one's own body scheme is observed in many mental status disorders.

Risk factors are numerous. In addition to neurological deficits and mental illnesses, they include acute severe infectious diseases with complicated course; craniocerebral injuries; encephalitis; [ 9 ] chronic metabolic disorders and hormonal imbalance; addictions to alcohol, drugs, computer games, unfavorable family environment, etc.

Stress, sometimes minor, can provoke a violation of self-perception. Especially when it is superimposed on chronic lack of sleep, physical overexertion, immunosuppression after an illness. Individuals who are prone to prolonged thinking and analysis of negative events and their role in them, suspicious, touchy, with inflated claims, unsociable and insecure, have a significantly higher risk of developing autometamorphopsia than mentally stable individuals.

There are usually several factors, and further stress against the background of mental exhaustion gives impetus to the development of this disorder.

Pathogenesis

The pathogenesis of disorganization of self-perception is considered as a violation of neurochemical balance in brain cells. Symptoms of autometamorphopsia are associated with functional and structural deviations in the perception system. [ 10 ]

Most symptoms of autometamorphopsia involve clusters of neurons that respond selectively to specific types of sensory input (for vision, particularly in cortical areas V1-V5). For example, area V4 of the extrasystostatic visual cortex responds selectively to color, while area V5 responds to motion. Both areas also respond to shape and depth, but bilateral loss of V4 function results in achromatopsia (inability to see color), while bilateral loss of V5 results in akinetopsia (inability to see motion). The inability to visually perceive vertical lines (plagiopsia) or lines at different angles is due to loss of function of the orientation columns, which are grouped across the horizontal layers of the visual cortex.[ 11 ]

Serotonergic, dopaminergic, GABAergic regulation is assumed to be impaired. There are various hypotheses for the development of autometamorphopsia, but the processes occurring in the brain are still beyond complete understanding. Provoked by a number of the above factors, the visual perception of one's own body is impaired, an internal representation of the structural organization of the body and/or its dynamic characteristics that does not depend on the will of the individual. The disorder occurs at the very first stage of higher nervous activity. The object, in this case the body or its part, is correctly identified, that is, the sense organs correctly reflect its qualitative characteristics, but distort the quantitative ones - shape, size, location, and the holistic representation that is formed is already incorrect. Depersonalization, one of the manifestations of which is autometamorphopsia - rejection of one's own body, is recognized as a protective reaction of the exhausted nervous system to mental trauma. Manifestation occurs suddenly immediately after stress and in some cases the condition can stabilize on its own. Often patients understand that their perception is impaired, but this does not depend on the will of the individual, and if the pathology is long-term, then over time the patient develops a persistent conviction of his physical disability.

Symptoms autometamorphoses

The first signs appear suddenly after acute or chronic stress - suddenly the self-perception changes completely or such changes occur periodically. Patients note that the period preceding the appearance of symptoms is characterized by a high level of anxiety and emotional stress, most patients experience a feeling of changes in their own body when going to sleep. There is usually no alienation from one's body, the sensations are sharp and distinct, attract attention. Although in some cases patients note alienation, the body is felt as if from the outside, as if it were someone else's.

Total autometamorphopsia is manifested by the perception of a proportional increase (macropsia) or decrease (micropsia) in the size of all parts of the body, their shape is usually perceived correctly. The degree of increase (decrease) can be different, sometimes the patient has a feeling of a huge body. It seems so big that the patient is afraid to enter a spacious room, so as not to get stuck. The apparent decrease can cause the patient, for example, a fear of drowning in a puddle. The body is perceived as distant and turned into a point. In some cases, such metamorphoses of perception are barely noticeable.

Partial autometamorphopsia is more common than total autometamorphopsia. Any part of the body may appear altered. The most common disorders have their own names.

Macromilia is the sensation of large hands. Both hands or parts of them, such as palms or fingers, may be perceived as enlarged. When falling asleep, the patient feels how huge his hands are. The "big hands" effect may be symmetrical or one-sided. Micromilia is the sensation of small hands, sometimes even microscopic.

In addition, it happens that one part of the body, for example, the left hand, seems enlarged, and the other, the right hand, seems smaller. This condition is called contrast autometamorphopsia.

The feeling of your legs being large and/or thick is called macropedia, and the feeling of them being smaller is called micropedia.

Often, distorted sensations concern the head - macro- and microcephalopsia. Any organ or part of it can be perceived incorrectly: tongue, nose, ears, neck, chest, stomach, genitals, and so on.

The unconscious internal representation of the shape of the body or its parts (autodysmorphopsia), their position (body allesthesia), and dynamic characteristics may be disrupted. [ 12 ]

Autodysmorphopsia is manifested in the fact that round parts of the body, for example the head, are perceived as triangular, rectangular, square, abnormally long or short, curved, spherical, etc. [ 13 ]

With body allesthesia, the feet may appear to be turned backwards, the back to the front, and the knees to the back.

The perception of the width of steps, intensity of gestures, speed of movement may be disrupted. The nature of movements may be perceived distorted, for example, convulsions - as rotational movements, smoothness seems intermittent.

Sometimes all parts of the body seem to be disconnected - the head or hands separated from the body, the eyes popping out of their sockets (somatopsychic dissociation). The whole body can seem to be made up of separate elements, like a construction set. The patient worries about its integrity and is afraid that it will fall apart. K. Jaspers called this condition "a symptom of the dissociated I."

Since the body scheme is understood as a set of unconscious information about the structural organization of the body, manifestations of autometamorphopsia also include incorrect ideas about the localization of sensations, for example, pain or tactile, the placement of emotions, for example, fear, in the throat or lower abdomen (Minor's symptom).

Patients perceive the manifestations painfully. In most cases, autometamorphopsia phenomena are accompanied by other psychopathological symptoms: anxiety, unreasonable fears (to drown in a puddle or to spread out on the floor), panic attacks, depression, social isolation. In the case of serious diseases, their symptoms are present: epileptic seizures, imperative voices, obsessive ideas, automatisms, ritual actions, etc.

Sometimes, in mild cases, it is possible to correct a distorted idea of body parameters by looking in the mirror. In this case, a person is convinced that everything is in order.

The duration of AIWS symptoms is usually from a few minutes to 26 days; however, symptoms can persist for 2 years or even for life. [ 14 ] An important detail is that after visual fixation on an object, metamorphopsia can sometimes occur after an interval of seconds to minutes. After this time delay, objects are perceived in a distorted way, but during the delay the perception process is not disturbed. In the historical literature, this phenomenon is explained as a sign of cerebral asthenopia (i.e. unusual fatigue of the perceptual system).

Complications and consequences

Autometamorphopsia may be a sign of a serious illness, so if this kind of trouble is prolonged, it is necessary to consult a doctor. Since this condition is often just a symptom of more significant mental disorders, it is known that in the initial stages any disease is much more treatable. The consequence of ignoring the symptoms of the disease is its progression and, ultimately, the emergence of resistance to treatment, worsening of the disease, loss of independence, and sometimes premature death.

Autometamorphopsia, not associated with a progressive mental illness, does not always self-terminate. In the initial stages, patients are critical of their condition, but its unnaturalness creates preconditions for constant reflection, the person thinks that he is going crazy. Obsessions, severe neurosis, depression may develop. Patients prefer isolation, lose social connections, self-respect, neglect work and family responsibilities, and often acquire dependence on psychoactive substances as a means of self-soothing and distraction. There is a high probability of committing illegal or suicidal acts.

Diagnostics autometamorphoses

Patients' complaints usually boil down to the fact that they suddenly have strange sensations of disproportion of their body or its parts: it seems disproportionately large or small, and in connection with this, new inconveniences appear: they are afraid to go outside, because they are small - they will be crushed; to enter a room - they will get stuck, because they are large; to go to bed, because huge hands will crush them, etc. Basically, patients emphasize that they understand - the sensations are apparent.

The doctor asks the patient in detail what preceded the symptoms, what illness he has, whether anything like this has happened to him before, how often he drinks, whether he takes any medications, whether he has other addictions. The family history, stress resistance, and cognitive abilities of the patient are analyzed. Since autometamorphopsia is one of the manifestations of depersonalization, the patient is offered to undergo specific tests.

In addition, a general health examination is prescribed - clinical blood and urine tests, a consultation with an endocrinologist and tests for blood glucose levels, thyroid hormones may be prescribed. If there is a suspicion that the patient may abuse psychedelics, a urine test is prescribed to detect traces of psychoactive substances and a consultation with a narcologist.

Hardware studies (MRI, EEG, ultrasound) are prescribed to exclude or confirm organic causes for the occurrence of symptoms of perception disorder. This is especially relevant in case of late onset, absence of factors that provoke it, symptoms of neurosis, depression, previous craniocerebral injuries.

Differential diagnosis

Differential diagnostics and establishment of a final diagnosis are carried out based on examination data. A diazepam test may be prescribed.

Autometamorphopsia is differentiated from other disturbances of perception – hallucinations and illusions. The object of hallucinations is imaginary, but naturally fits into the environment. The patient lacks criticism of his sensations. In illusions, a real object is taken for something completely different. In autometamorphopsia, the object is real and recognizable, but its characteristics are transformed in the patient’s consciousness. Patients generally understand the absurdity of their sensations.

Like autometamorphopsia, functional hallucinations occur in the presence of a real object. Their occurrence is provoked by real stimuli, for example, under the sound of the wind, the sound of pouring water or the clatter of train wheels, imaginary sounds, smells, tactile sensations appear in parallel. The patient perceives both real sounds and imaginary phenomena at the same time, they coexist in his consciousness, and when the irritant ceases to act, they immediately disappear.

Treatment autometamorphoses

Autometamorphopsia, which suddenly appeared against the background of a psychotraumatic situation as an isolated neurotic syndrome, that is, regular recurrent attacks of distorted perception or a constant disorder, usually confuses people. Thoughts about losing their minds arise. What to do? Is it possible to cope on your own? After all, you don’t want to immediately use heavy artillery – psychotropic drugs. Information about their side effects is not inspiring.

Considering that we are talking about the manifestation of depersonalization syndrome, then similar measures must be taken. If the patient feels the desire and strength to get rid of the disorder on his own, then, without delay, he must get down to business (How to get rid of depersonalization on your own?).

Local treatment with rTMS (repetitive transcranial magnetic stimulation) may have global therapeutic effects in Alice in Wonderland syndrome and verbal auditory hallucinations.[ 15 ]

In difficult cases, resort to drug treatment. It is carried out only by prescription and under medical supervision, self-medication is strictly excluded, since psychotropic drugs cause a lot of side effects, addiction and withdrawal syndrome (drug therapy of depersonalization). You can resort to homeopathic treatment. The drugs used in alternative medicine are not toxic, and properly prescribed treatment can be very effective. However, it also needs to be carried out under the supervision of a specialist.

Psychotherapy gives a good effect. It is used both independently and in combination with medication. A psychotherapist can give recommendations on the use of some methods of working on yourself at home. In general, without the desire and efforts of the patient himself, the problem cannot be dealt with.

In cases where the cause of autometamorphopsia is a mental or somatic pathology, it is necessary to treat the underlying disease. When it is cured, or in cases of schizophrenia or epilepsy, when stable remission is achieved, the symptoms of the body scheme disorder disappear, usually first.

Alice in Wonderland Syndrome (AIWS) has no proven effective treatment, but treatment programs for possible causes of the disorder are used to alleviate the condition. Chronic cases of AIWS are completely untreatable. A person suffering from the disorder may have distortions and hallucinations several times a day. True, a person may be frightened, agitated, and panicked. These manifestations are not harmful or dangerous, and will likely disappear with time.

Cases of AIWS have been reported with the use of montelukast, [ 16 ] a mast cell stabilizer. Furthermore, AIWS has been linked to Lyme disease, [ 17 ] mononucleosis [ 18 ] and H1N1 influenza infection. [ 19 ], [ 20 ] Further studies regarding this association are not yet excluded.

In general, the treatment plan consists of migraine prevention (anticonvulsants, antidepressants, calcium channel blockers, and beta blockers). Following a migraine diet regimen provides tremendous relief.

Complete remission was achieved in 46.7% of all patients, and partial or temporary remission in 11.3%. In chronic conditions such as epilepsy and migraine, complete remission was achieved very rarely.[ 21 ]

Prevention

To prevent the occurrence of self-perception disorders, as well as to prevent relapses, it is recommended to analyze and adjust your attitude to the world, requests, optimize goals and objectives in accordance with real possibilities. Bring more positivity into your life, find an activity to your liking, increase physical activity. It has been established that physical activity promotes the production of endogenous antidepressants. It will be useful to undergo a course of rational psychotherapy. At the same time, no one has canceled the benefits of rational nutrition and the absence of bad habits.

In some cases, when a mental disorder was caused by the use of psychoactive substances, it is necessary to change the social circle and, if possible, the place of residence.

Forecast

Autometamorphopsia as a neurotic post-stress disorder is prognostically favorable. People who have taken measures to get rid of pathological manifestations almost immediately have every chance to quickly cope with the situation. The prognosis almost always depends on the desire and efforts of the patient himself.

In advanced cases, autometamorphopsia can be difficult to cure; in some cases, the disorder becomes chronic and recurrent, and complications develop against its background. However, it is worth noting that with autometamorphopsia of neurotic genesis, significant personality changes are not observed.

If a body schema disorder is observed in a symptom complex of schizophrenia, epilepsy, organic brain pathologies, etc., then the prospects for recovery depend on the prognosis of the underlying disease.