Rare and Unusual Psychiatric Syndromes: A Primer

Christoph U. Correll, MD; Bret S. Stetka, MD; Ariel Harsinay


July 23, 2018

Alice in Wonderland Syndrome or Todd Syndrome

Alice in Wonderland syndrome (AIWS) or Todd syndrome is a neurologic condition in which a patient's sense of body image, space, and/or time are distorted. Patients may experience micropsia, Lilliputian hallucinations, or other sensorial distortions, including altered sense of velocity.

AIWS is a result of change in perception as opposed to the eyes themselves malfunctioning. The most prominent and often most disturbing symptom is that of altered body image, in which the person is confused as to the size and shape of some parts of (or all of) his or her body. These symptoms can be alarming, causing fear or even panic. Distortions can recur several times a day and may take some time to abate.

AIWS is often associated with migraines, brain tumors, or use of psychoactive drugs, and can also present as the initial sign of the Epstein-Barr virus or other infections. Rest is found to be the best treatment. If associated with migraines, treatment is the same as that used for migraine prophylaxis, including anticonvulsants, antidepressants, beta-blockers, and calcium-channel blockers, together with strict adherence to the migraine diet.

A study of AIWS in the past year has identified a link between the syndrome and recurrent depressive disorder. Underlying functional disturbances are found to overlap in both conditions, and thus research points toward a common comorbidity between the conditions. The study mentions two patients who, when slipping into depressive episodes, experienced delusions, such as believing that their hands and feet were shorter than they actually were. The overlap between the two conditions is believed to be due to the constriction of time and body experiences that often occurs in major depression.[8]

Jerusalem Syndrome

Jerusalem syndrome is characterized by religiously themed obsessive ideas, delusions, or other psychosis-like experiences that are triggered by, or lead to, a visit to the city of Jerusalem. It is not restricted to any religion or denomination.

Jerusalem syndrome seems to emerge when people with a history of mental illness visit Jerusalem. The syndrome seems to consist of transient psychotic delusions, which tend to dissipate within a few weeks after being removed from the area.

Symptom-based approaches or careful withdrawal of antipsychotic drugs after cessation of the psychosis in those people in whom antipsychotic treatment is needed should be attempted. However, Jerusalem syndrome needs to be distinguished from a first or recurrent psychotic disorder that requires long-term antipsychotic treatment.

Case studies of Jerusalem syndrome have included visitors Jerusalem believing that they are biblical figures, such as a Canadian tourist who believed he was the Israelite warrior Sampson and tried to destroy the Western Wall; an Austrian man who demanded that the chef in his hotel prepare him a feast reminiscent of the Last Supper; and an Irish tourist who rushed to a hospital, believing that she was the next Virgin Mary and was about to give birth despite not being pregnant.[9]

Paris Syndrome

Paris syndrome is an unusual state exclusive to Japanese nationals who experience a mental breakdown while visiting the famous French capital, but it has also been observed in Japanese tourists visiting France or Spain in general. Paris syndrome appears to be a severe form of culture shock that can express itself in many different forms, including physical and emotional symptoms of anxiety, derealization, and depersonalization, as well as acute delusional states, persecutory ideas, and hallucinations.

Of an estimated 6 million Japanese tourists who visit the city every year, approximately one to two dozen experience this illness. Usually, people with Paris syndrome do not have a history of psychiatric problems. It is hypothesized that Paris syndrome emerges because these tourists hold a romanticized and idealized vision of what Paris will be like, but are then confronted with a language barrier, different cultural norms, or other aspects that destroy their preconceived notions. Physical and mental exhaustion have also been attributed with the onset of the syndrome. Psychotherapeutic and supportive approaches should be used, and comorbid conditions should be identified and managed as appropriate.


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