title: Treatment of Alice in Wonderland syndrome and verbal auditory hallucinations using repetitive transcranial magnetic stimulation: a case report with fMRI findings.
abstract: BACKGROUND
  Alice in Wonderland syndrome (AIWS) is a rare cluster of CNS symptoms characterized by visual distortions (i.e. metamorphopsias), body image distortions, time distortions, and déjà experiences. Verbal auditory hallucinations (VAHs) are the most prevalent type of hallucination in adults with or without a history of psychiatric illness. Here, we report the case of a woman with AIWS, long-lasting VAHs, and various additional perceptual and mood symptoms.
  
  
  METHODS
  Semi-structured interviews were used to assess symptoms, and functional MRI (fMRI) was employed to localize cerebral activity during self-reported VAHs. Treatment consisted of repetitive transcranial magnetic stimulation (rTMS) at a frequency of 1 Hz at T3P3, overlying Brodmann's area 40.
  
  
  RESULTS
  Activation during VAHs was observed bilaterally in the basal ganglia, the primary auditory cortex, the association auditory cortex, the temporal poles, and the anterior cingulated gyrus. The left and right inferior frontal gyri (Broca's area and its contralateral homologue) were involved, along with the dorsolateral prefrontal cortex. Interestingly, synchronized activation was observed in the primary visual cortex (areas V1 and V2), and the bilateral dorsal visual cortex. The higher visual association cortex also showed significant, but less prominent, activation. During the second week of rTMS treatment, not only the VAHs, but also the other sensory deceptions/distortions and mood symptoms showed complete remission. The patient remained free of any symptoms during a 4-month follow-up phase. After 8 months, when many of the original symptoms had returned, a second treatment phase with rTMS was again followed by complete remission.
  
  
  CONCLUSIONS
  This case indicates that VAHs and metamorphopsias in AIWS are associated with synchronized activation in both auditory and visual cortices. It also indicates that local rTMS treatment may have global therapeutic effects, suggesting an effect on multiple brain regions in a distributed network. Although a placebo effect cannot be ruled out, this case warrants further investigation of the effects of rTMS treatment in AIWS.
authors: Parnassia Bavo Group, The Hague, The Netherlands. jd.blom@parnassiagroep.nl
authors: Jan Dirk
authors: JD
authors: Blom
authors: Jasper
authors: J
authors: Looijestijn
authors: Rutger
authors: R
authors: Goekoop
authors: Kelly M J
authors: KM
authors: Diederen
authors: Anne-Marije
authors: AM
authors: Rijkaart
authors: Christina W
authors: CW
authors: Slotema
authors: Iris E C
authors: IE
authors: Sommer
mesh_terms: D000328:Adult; D001828:Body Image; D001921:Brain / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006212:Hallucinations / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D012649:Self Concept; D013998:Time Perception; D050781:Transcranial Magnetic Stimulation / Q000379:methods*; D016896:Treatment Outcome