Professional Documents
Culture Documents
Address for Correspondence: Arturo G. Lerner, MD, Lev Hasharon Mental Health Medical Center, POB 90.000, Netanya 42100, Israel
alerner@lev-hasharon.co.il, lerneram@internet-zahav.net
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Isr J Psychiatry Relat Sci - Vol. 51 - No 4LSD-associated
(2014) Alice in Wonderland Syndrome
The patient gave informed consent for the publication The unique clinical aspect of this case is the absence
of his case. To the best of our knowledge this is the first of almost all the recurrent common visual disturbances
report in the professional literature. described in the professional literature (11, 12, 15-20).
Moreover, the striking resemblance to former description
of AIWS in other pathological contexts is remarkable. As
Case report the main perceptual disturbance is visual, much of the
Mr. A is a 26-year-old single male university student who research pertaining to potential mechanisms underlying
completed compulsory military service and did not have these disorders focus on the Lateral Geniculate Nucleus
any previous police or criminal records. He had a five- (LGN). The LGN, which is located in the thalamus, has
year past history of occasional social cannabis and alco- been associated to visual perception pathways and may be
hol use during weekends and holidays. He also reported affected by LSD toxic effects (21, 22). These toxic effects
recreational use of LSD. He fulfilled DSM-5 full criteria might result in temporary impairment at LGN which
for tobacco use disorder (11). During LSD intoxication might lead to benign disinhibition of visual processors
he reported the presence of four frequent visual illusions and the genesis of recurrent visual disturbances (23).
namely, macropsia, micropsia, pelopsia and teleopsia. These Transient absence, deficiency or insufficient inhibitory
visual distortions were reported when looking at still or activity of the visual pathway may permit and enable
moving objects, human and non-human beings. When visual stimulus to persist. This proposal may explicate
interviewed Mr. A unhesitatingly and precisely attributed reported visual disturbances, in this case macropsia,
psychedelic experience solely to LSD intake. Two days after micropsia, pelopsia and teleopsia, which may reflect
completely stopping all substance use due to a longer than the failure of each respective responsible visual function
expected hallucinogenic experience associated with slight (15, 23-25). Macropsia and micropsia may arise from
anxiety, he surprisingly noticed the returning of some visual magnification or miniaturization of perceived images
imagery previously experienced. For example, books were on the grounds of abnormal cortical processing (24, 25)
seen slightly closer, chairs were seen slightly further away, related to LSD induced damage at cortical levels (17). It
his hands were seen larger than they actually were, his dogs could be additionally speculated that LSD intake might
head was seen smaller (13). Interestingly some still objects produce short-term limited and reversible damage of the
were observed slightly moving back and forth and perceived LGN leading to dysfunction of the parvocellular cells
closer, i.e., pelopsia, and further away, i.e., teleopsia (14). He which may modulate the perception of forms and shapes,
clearly did not expect the return of this visual imagery. As the namely, macropsia and micropsia, and magnocellulars
condition persisted, Mr. A started expressing preoccupation cells which may modulate the perception of movement
and discomfort. He felt intimidated and disheartened and of still objects, namely, pelopsia and teleopsia (17, 23-25).
sought a psychiatric consultation. On examination there was A single clinical case report has obvious limitations. It
no prior or present history of acute or chronic neurological, should be stressed that cannabis use was not reported as
ophthalmological or other co-morbid medical illnesses or the cause of any hallucinogenic experience. The primary
co-occurring psychiatric disorders. A complete physical, assumption is that the patient is capable of remembering
neurological (including EEG) and laboratory examinations the experienced trip and adequately describe the cur-
showed no abnormal findings. rent phenomena. Possible LSD-inflicted transient and
Mr. A was not interested in chemical pharmaco- permanent damage at LGN and other nuclei is poorly
logical treatment and agreed to psychiatric follow-up. and insufficiently understood. The specific development
After approximately one year these visual disturbances of AIWS after LSD consumption in the specific patient
completely disappeared. remains largely unexplainable. research may increment
our knowledge regarding the mechanism of action of LSD
and related clinical phenomena.
Discussion To our knowledge this is the first case of HPPD-
The suggested mechanism underlying recapitulation associated AIWS, which may contribute to clinical
and reproduction of visual disturbances originally expe- knowledge. Exploring the possibility of HPPD, in its
rienced during LSD intoxication has been extensively many forms, among individuals with prior LSD use is rec-
discussed (15-17). Comprehensive understanding of ommended. However, conclusions from an uncontrolled
this clinical syndrome remains unanswered. case report should be drawn with appropriate caution.
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Arturo G. Lerner and Shaul Lev Ran
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