A 67-year-old man in Japan told doctors that he, other people, and objects around him were growing taller and larger, while his wife seemed to be rapidly shrinking. At the same time, he saw countless small bugs crawling over his entire body.
Psychiatrists at Tohoku Medical and Pharmaceutical University in Sendai described the case in April 2026 in Case Reports in Psychiatry. The man had Alice in Wonderland syndrome, a rare disorder of distorted perception, along with Ekbom syndrome, also called delusional parasitosis.
Both appeared during his first manic episode of bipolar I disorder. To the authors' knowledge, it is the first reported case of Alice in Wonderland syndrome emerging with a bipolar I manic episode and the first documented case of delusional parasitosis occurring alongside the syndrome.
Faces That Moved Closer and Time That Sped Up
The man had been diagnosed with depression 22 years earlier and had taken the same antidepressant and sleep medication for years. He had no history of migraine, epilepsy, head injury, or substance abuse and had not been drinking alcohol for several years.
His manic symptoms and perceptual distortions began together. He was talkative, hyperactive, irritable, and sometimes violent, slept little, and had racing thoughts. He was admitted to the psychiatric unit two weeks after symptoms started.
He described the size changes vividly: "I, others, and things around me are getting taller and bigger in height and volume, and my wife seems to be rapidly decreasing in size."
His visual distortions went further. Faces seemed to approach him, a table tennis ball appeared to change shape, and the faces of a white dog and his family members looked completely black. Time was distorted too. He said other people's speech sounded louder and faster, time seemed to pass much more quickly, and cars on television appeared to move faster.
He also lost his grip on what felt real. When a television report said Japan's national table tennis team had won a world championship, he insisted it could not be real. To confirm his own identity, he repeatedly called friends and his own home and checked his driver's license and a copy of his family registry to reassure himself of his name.
Bugs, Itching and Compulsive Cleaning
The Ekbom symptoms were distressing. He described unbearable itching and saw small bugs crawling all over his body. He compulsively washed his bedclothes and curtains and cleaned windows and doors throughout the day and night.
The authors suggested the parasite delusion developed as a secondary effect of heightened touch sensitivity and itch perception. Altogether, they wrote, his abnormal perceptions spanned vision, touch, hearing and the sense of time.
Delusional parasitosis is a firm belief in being infested with parasites despite no evidence of infestation. A review of Ekbom syndrome in the International Journal of Molecular Sciences describes the complex medical evaluation it requires.
What Brain Scans Showed During the Episode
Blood tests found no problems with his liver, kidneys, thyroid, or metabolism, and there were no signs of infection. MRI showed no significant brain shrinkage, and imaging of his brain arteries was normal.
On his seventh day in the hospital, doctors performed single-photon emission computed tomography, or SPECT, which maps blood flow in the brain. It showed significantly reduced blood flow in the left parietal cortex, the right precuneus, and the right posterior cingulate region. Blood flow in the visual areas at the back of the brain appeared relatively increased, though not to a statistically significant degree.
Two months later, blood flow had improved in the right posterior cingulate and precuneus regions, while the relative increase in the visual areas remained. He was treated with valproic acid and olanzapine, standard medications for mania. A cognitive screening test scored 20 out of 30, indicating moderate impairment, which the authors said should be interpreted cautiously with continued follow-up.
The researchers proposed that his symptoms reflect an imbalanced brain network involving connections to the occipital cortex, the brain's visual center. That fits a study in Annals of Neurology that mapped lesions from 37 adults with the syndrome to shared connections linking the brain's body-perception region with the parietal cortex. The authors acknowledged a limitation: many studies have found lower blood flow in frontal and parietal regions during mania, and they could not fully separate the effects of the manic state from those of the syndrome.
A Rare Syndrome Still Without Formal Criteria
Alice in Wonderland syndrome takes its name from Lewis Carroll's novel, in which Alice grows and shrinks. Fewer than 200 cases were reported from 1952 through a systematic review in Neurology Clinical Practice, and the condition is not listed in the DSM-5, the main U.S. psychiatric diagnostic manual.
It is most often linked to migraine, infections, drug intoxication, and brain lesions. Mood disorders are a rarer setting. The authors counted three earlier cases in men with major depression, including a 67-year-old man whose scans showed heightened visual-area activity, and one in a woman with bipolar depression. The Tohoku team argued that more case reports with functional brain imaging are needed to establish diagnostic criteria.
For families, the case is a reminder that sudden perceptual changes, confusion or new beliefs about infestation in an older adult warrant prompt medical and psychiatric evaluation, since causes range from mood disorders to strokes and infections.
Key Questions Answered
What is Alice in Wonderland syndrome?
It is a rare condition that distorts perception, making the body, people or objects seem larger, smaller, closer, or oddly shaped, sometimes with a distorted sense of time.
What is Ekbom syndrome?
Also called delusional parasitosis, it is a fixed belief that one is infested with parasites despite no evidence of infestation.
What made this case unusual?
The authors said it was the first reported case of Alice in Wonderland syndrome with a bipolar I manic episode and the first with coexisting delusional parasitosis.
What did the brain scans show?
SPECT showed reduced blood flow in the parietal, precuneus, and posterior cingulate regions during the episode, with partial improvement two months later.
How was he treated?
He received valproic acid and olanzapine, standard medications for managing mania.
Published by Medicaldaily.com
