Rude Awakenings

Carol Dresel has restless-legs syndrome. Coy Replogle flails around and whacks his wife. Local sleep researchers hope to put such nightmares to rest-- and find out what dreams are made of.

The dreams seemed harmless enough at first. Nightmares, shadow men, phantoms. But who doesn't have nightmares? Coy Replogle figured it was nothing to worry about.

But the dreams kept getting worse.

"I would be jogging," he says. "It was usually at night. Suddenly, these guys would come out of the bushes, jump in front of me, and act like they were going to grab me. Other times I would be in the grungiest alleys in town. I would have no idea what I was doing in such a place. And the men looked like they just came out of a coal mine, filthy and dark clothing. I don't think I could describe them so that anybody would be able to recognize them. Just dark, shady people." It got so the dream people were coming after him almost every night.

And then, Replogle started fighting back.

"One time I was evidently very restless and my wife put a hand on my shoulder and I just went whump!--I punched her." Replogle's days were comparably quiet. He had no problems with his work at the factory where he managed an entire department.

But in the early hours of dawn, the couple's suburban bedroom became the staging ground for his brutal dreams: He would strike his wife, mistaking her for one of his demons. He would curse, and kick his bed. He would fall on the floor flailing. Once he fell face-first into the night stand, cutting himself badly.

"That's the way these dreams go," he says. "They're very pleasant and normal dreams, and then all of a sudden something triggers the disturbance. You know, someone would be in my face, something like that, and then I would just lash out to protect myself.

"It was always the strangest feeling," he adds, making a fist. "They're right there and ready to fight and I take a swing at them"--he shows his empty hand--"and it's like going through a ghost."

When Replogle finally checked into the Minnesota Regional Sleep Disorders Center, an internationally known clinic in the Hennepin County Medical Center in Minneapolis, the doctors told him his condition is not psychological, but physiological. He suffers, they explained, from a rare, mysterious--but treatable--malady called REM-Sleep Behavior Disorder (RBD), usually found in older men. Some misfire in Replogle's brain allows him to act out his dreams.

The doctors at the HCMC sleep lab knew his condition well; they were the first to identify the disease in a 1987 article in the Journal of the American Medical Association. In fact, RBD is just one of the bizarre, frightening, and sometimes dangerous syndromes that haunt the sleep center's patients. It's one of a group of peculiar sleep disorders called the parasomnias.

The parasomnias are so named to distinguish them from hypersomnia (too much sleep) and insomnia (not enough). They're sort of a catch basin for sleep problems no one understands: sleepwalking and nightmares are the most common. Other parasomnias are stranger and more destructive, like sleep terrors, restless-legs syndrome, and panic disorders.

And then there are the patients who suffer from parasomnias that don't yet have names. The boy who turns into a cat at night--prowling his room growling, biting the doorknobs and dragging his mattress around with his teeth--falls into this category. So does the woman who sits up in bed and rocks all night long, singing in her sleep.

Frequently, the center's sleep specialists know how to treat the symptoms. But often they're left guessing what causes them: They speculate that some chemical is out of balance, some tiny structure in the brain stem is frayed, some signal out of whack. Ultimately, they're convinced the answers will come from studying the brain.

That sounds like a simple idea. But it signals a fundamental change in the science of sleep and dreams. There are still those who believe that dreams reveal some secret desire, some repressed fear, that psychology rules consciousness. But the doctors at the sleep center consider sleep and dreams--and consciousness itself--to be physical properties of the brain. That's a radical idea, one that shakes the very foundation of who we think we are. For Coy Replogle and thousands more like him, this is no mere academic debate: It marks the difference between being "crazy" and being cured.

The Sleep Disorders Center takes up two floors of a wing in HCMC's Chicago Avenue building in Minneapolis. On the first floor are offices and meeting and examining rooms. On the second is the sleep lab, where every night, under the constant watch of technicians, up to six patients sleep.

Down the hall in the "living room," a television is up loud, lulling a patient toward sleep. In another room nearby, technician Dean Phillips is hooking up a patient with the help of a colleague. Steve (not his real name) is here tonight because he's worried about apnea. Patients with apnea actually stop breathing during their sleep. It's the most common problem people bring to the sleep lab, affecting as many adults as asthma and diabetes, and is easily treated with a pressurized sleep mask.

Phillips uses a special glue and a small air dryer to attach pill-sized, gold-plated electrodes to Steve's skin: two to measure eye movements; three to measure the muscle tone of his chin; another dozen to measure the electrical activity in his breathing muscles--diaphragm, chest, intercostals. A special sensor taped near his nose measures airflow in and out of the lungs. A finger clip keeps track of the amount of oxygen in his blood.

Finally, anywhere from five to 10 electrodes go on Steve's head to give the techs a kind of picture of his brain activity, an EEG. "You had a nightcap tonight?" Phillips grins. "I'll be able to tell."

Forty-five minutes later, every electrode is in place and tested. A maze of brightly colored wires snakes up through Steve's pajama tops and off his head. Phillips gathers them into a thick ponytail and tapes them together. Then he ushers Steve to a bed in what looks like a cross between a budget hotel room and a hospital room.

Steve lies down and Phillips heads back to his observation post in front of a tall polygraph console covered with hundreds of tiny switches and dials, all hooked up to Steve's wires. Next to the console sits a small television screen broadcasting an image of the patient's bed. Each patient in the sleep lab has a similar setup: The console converts all the pulsing energy picked up by the electrodes into clear signals that in turn cause a dozen pens on the polygraph to jump and dip as the paper scrolls past underneath. By morning, Steve will have generated a giant book some 4 inches thick, a printed record of his sleep--every breath, twitch, and dream.

Most of what is known about sleep comes from these charts (the rest comes from experiments on cats) and it's a pretty fuzzy picture. The sensors act like microphones, picking up any electrical noise in the skull. Because they're not attached directly to brain tissue, Phillips explains while he flips a button and inspects the result on the polygraph paper, the sensors record only general brain activity.

"They're on top of the muscle, which is on top of the bone, which is on top of the brain," he says. "And that's a lot of interference." It is possible to implant tiny electrodes inside individual brain cells--but only in animals.

But even through all that tissue, the EEG tells a lot about our brains. It responds to subtle changes in brain chemistry and electrical activity, whatever the cause: street drugs, for example, or medication; insanity or sleep. "An alcoholic has a very faint EEG reading," Phillips says. "And if you've been on Prozac ever in your life, the waves are wild, all over the place."

Phillips picks up a phone near the TV monitor and asks Steve to move his eyes, his legs, take a deep breath. He scribbles in red pen on the printout after each test. Then he shuts off the light and wishes Steve a good night.

Steve rolls over on his back and closes his eyes while Phillips keeps an eye on the printout. It shows that Steve is awake: His eye movement is steady, without wild variations. His brain waves are random, but slowly start to resemble the more regular alpha waves of drowsiness. Whenever Steve shifts position, scratches, or sighs, all the pens sensing muscle activity respond suddenly by tracing out bouncing, heavy spikes. Phillips notes these jolts on the chart: "rolled onto back," or "coughed." As Steve relaxes, so do his readings.

Phillips says most of us mistakenly believe it takes a long time to fall asleep. In fact, it only takes a few minutes for a normal person to descend into the first stages of sleep--even in an unfamiliar place like the sleep lab, and even wired to a maze of electrodes. Steve passes the threshold in just eight minutes, drifting in and out of the first four stages of sleep. His EEGs open up into wider, slower waves. Sleep spindles, short bursts of electricity from the thalamus, show up on his chart. Then the K-complexes appear: wide, regular waves that come more and more frequently, until they take over completely during deeper stage four, or delta sleep.

An hour later, everything suddenly changes. His muscle tone goes flat and his chin sensor shows almost no electrical activity at all. But the polygraph pen is bouncing around at random. His brain appears to be awake. The readouts from his left and right eyes are frenzied, waving up and down, the two lines pinching together and flipping apart as Steve looks to his left and to his right. On the television screen, Steve looks just as he did in slow-wave sleep. If anything, he appears to be even deeper in sleep, utterly motionless. He has entered rapid-eye-movement, or REM sleep, the stage that gives us our most vivid dreams.

It used to be commonly held that sleep was merely the absence of brain activity, that it was essentially the same thing as rest. But the polygraph proves that isn't the case. In fact, our brains are even more active during some phases of sleep than they are when we are awake--so active that our brain stem has to jam the motor signals going to the spinal cord to keep us from getting up and acting out our dreams.

The picture gets even more puzzling when you factor dreams into the mix. Coy Replogle relates this dream: "My wife and I were out walking in the wintertime. There was snow on the ground. We were walking and came to a little slope down to a creek bed. I started down and I held out my hand to help her across the ice. Then my feet slipped up, and I went feet-first through the ice. The creek bed must have been 2 feet deep. I could see myself underneath the water and the ice, bubbles coming up. I knew I had to get out of there and the only way to do it was to break the ice. I flipped over on my hands and knees... and I woke up."

Experiments show which parts of the brain are active during such a dream: Even though his eyes are closed, he's hallucinated an entire snowy landscape. So his visual pathways are firing away. His motor pathways are active, too (everyone knows the feeling of slipping down a slope--or flying, or running, or trying to--in a dream). He also feels fear. The part of his brain that controls emotions is sparking.

Similarly, you can tell which parts of the brain are not functioning, especially when you look at hundreds or thousands of similar dream reports: Smell, taste, and sensations of temperature and pain show up rarely, if ever. Studies indicate that memory doesn't function, or that it operates differently when we are asleep. Also lacking from the dreaming brain is insight--we seldom realize we are dreaming.

One of the more radical theories, one supported by the everyday occurrences in the sleep lab, holds that we are literally insane when we dream. "Four or five times a night, roughly every hour and a half, we become clinically insane," writes Harvard researcher Bob Stickgold. "We begin to hallucinate. We see things that aren't really there. We hear voices when in reality no one is speaking. Stories unfold before us, around us, including us, and we are deluded, believing it all to be true. We become paranoid or filled with delusions of grandeur. Impossible things happen without notice. People appear and disappear and change into other people. One moment we're in Boston, the next in Paris and we accept it all as normal.

"If we did this while walking on the streets in the daytime, we could only hope that some kind person would lock us up."

But there's no sign of this delirium in Steve's room in the sleep lab. On screen, he appears to be utterly calm. While he sleeps, the techs hurry from station to station. Then a kind of peace settles over the lab as one by one the patients fall asleep. Faint snores filter through the tinny speakers on the TV monitor. Someone shifts and sends their polygraph pens scratching frantically. In bed and on paper, they drift in and out of REM sleep until morning.

It's been some 15 years since the HCMC sleep team saw its first few patients who acted out violent dreams. One of the first, Jones (again, not his real name), described his nightmares: One night he dreamed he was back in high school playing halfback with a tackle moving in on him. He woke up after he smashed into his dresser. Another night he dreamed he was driving a motorcycle. A second motorcycle was following him, trying to run him off the road. He kicked out at it--and struck his wife. He dreamed he was trying to shoot someone and woke crouched over the bed, sighting down an imaginary barrel.

The doctors couldn't believe he was really dreaming REM-sleep dreams. That would violate a basic rule: The body is paralyzed during REM sleep. Maybe it was sleepwalking, or some other non-REM problem.

Jones came into the sleep lab for observation. There, judging from his polygraph, he had a fairly normal night: wakefulness, slow-wave sleep, not much REM sleep, and some nighttime "arousals" during which the patient woke up and then quickly dropped back to sleep. But the lab tech described these waking periods as bizarre arousals. The man moved around, but he appeared to be sleeping.

When Dr. Mark Mahowald, the neurologist who runs the center, examined a videotape of the episodes and compared it to the polygraph, he was even more confused. "One of the technologists was in during one of these episodes and it was clear on the videotaped interaction that this patient had not been awake, but had in fact been asleep," he remembers. "He reported dreams that correlated and corresponded with the observed behavior. But if you just looked at the data--without the technician, without videotape--it looked like the patient woke up."

Jones's EEG was cranking away. So were his chin sensors, the ones that measure muscle tone. But he was clearly dreaming. "This guy sat up and threw punches," remembers Dr. Carlos Schenk, the staff psychiatrist. "But otherwise the evidence was overwhelming that he was in REM sleep."

Andrea Patterson, the sleep-lab manager, remembers the confusion. "I remember how difficult it was to look at the data and believe what I was seeing." What they thought they were observing seemed crazy: that Jones's brain had failed to jam the signals to his spinal cord. His muscles were jumping to his dreaming mind's commands. He was acting out his dreams.

A 30-year-old animal experiment finally confirmed the doctors' hunch. In the late '50s, the French neurologist Michel Jouvet cut the neurons that cause cats to be paralyzed during REM sleep. His findings, as summarized in the journal Neurology, were conclusive: "After adequate lesions the cat has dramatic... behavior during REM sleep, seeming to fight imaginary enemies or to play with an absent mouse, striking out with forelimbs and manifesting fear reactions.... During all this hallucinatory behavior, the nicitating membrane and the pupils are myotic, indicating that the animal is asleep."

What the cats couldn't tell the sleep-center doctors, but RBD patients have, is that the dreams are different, too. "It's not just a behavior disorder," Schenk explains. "It's also a dream disorder, because these patients enact unusual and violent dreams involving a lot of physical activities or confrontations with humans or animals. They don't act out their normal dreams."

A little tinkering and a happy accident led the doctors to a treatment. Jones twitched when he was trying to sleep. They treated his leg jerks with the drug Klonopin. "Lo and behold," says Schenk, "it worked on his RBD, too." He doesn't know how or why, but Klonopin jams the motion signals going from brain to spinal cord. Later, the doctors published their findings, first in the journal Sleep and then in the prestigious Journal of the American Medical Association, putting the HCMC sleep center on the map.

"We were very excited about it," Mahowald says. "But for many years it was called the 'Minnesota Disease.' People thought they weren't seeing it, when in fact they just weren't appreciating it. They would say that REM behavior disorder only happens in Minnesota. Now it's very well accepted."

For the patients who suffer from the disorder, the discovery and successful treatment of RBD is a relief. The rest of us learn some interesting information about our bodies. First of all, RBD illustrates why our bodies are paralyzed during the vivid dreams of REM sleep: because our brains are sending inappropriate messages to our bodies. If that is true, then it follows that the imagery of dreams, the movement we feel in dreams, is a result of motor neurons firing as opposed to something conjured by the psyche.

"A vital amount of the high energy that exists in REM sleep is devoted to inhibiting the muscles," Schenk explains. "It's like a taboo against movement. And that's very interesting because in non-REM sleep we still have muscle tone; there's passive withdrawal of the urge to move. So you don't need the muscle paralysis. If there's not going to be the urge to do something you don't need the inhibition. It's only when you have a strong urge to do something, i.e., in REM sleep, that you get the active inhibition of muscles."

So dream motion and waking motion are the same--but in normal dreamers, the signals never make it to the muscle. It turns out that "seeing" in dreams is a similar event. The structures in the brain that control vision are pulsing away, but no signals are coming in from the eyes. What we see in dreams are images generated by the brain itself.

None of this tells us why we dream. But it must be something important, because sleeping puts us at incredible risk. Imagine it: Not only are we paralyzed during sleep, but we're cut off from the world. When we're dreaming, we can't regulate our own body temperature. We can't see, feel, hear, or smell danger. Our brains are completely closed off, and at the same time scrambled with delusions and hallucinations.

When Carol Dresel was 30, right after the birth of her last child, she stopped sleeping. Or rather, she found herself unable to sleep because, suddenly and of their own accord, her legs began thrashing during the night. "There's no pain, no twitching, no aching," she says. "I just can not hold my legs still."

Her husband, Howard Dresel, suffered along with her. "She would thrash all the time," he says. "Very often she would turn herself completely around in the bed, head where her feet should be, feet up on the pillow thrashing all night long. She would just be on the move all the time. She just could never fall asleep. It was like, say you were lying down on your bed and your child poked you with a pin. You're going to just twitch; you're going to jerk. Or more like somebody walks up behind you and gooses you."

At first it only happened in the early evening. But over the years it got so bad she spent most of the night wandering around the house in a kind of trance. "I had to keep my body moving." From the bedroom she would roam to the kitchen, where she snacked on sweets compulsively, and often without any memory of having done so. Then she would continue wandering, down to the basement or out into the garage.

"One time I looked all over the house for her," Howard recalls. "In the garage, in the car. She was in the closet. It's just a little coat closet. There she was, wadded up in a ball in the fetal position trying to sleep. Five-thirty in the morning she would just drop. She'd wear herself out."

For 23 years, Dresel bounced from doctor to doctor taking desperate remedies. She tried vitamins, acupuncture, injecting homeopathic medicine, walking, and every imaginable sleeping pill. But instead of getting better, her condition grew steadily worse. "She told me several times she attempted to jump off the bridge over the river, it got so bad," Howard says.

When HCMC's Schenk examined Dresel, he recognized her condition as a sleep disorder called restless-legs syndrome, which doctors believe is essentially a dopamine deficiency. Dopamine is one of several chemicals called neurotransmitters that convey electrical impulses from one brain cell, or neuron, to the next, in this case among the motor neurons. Schenk prescribed a dopaminergic drug, and the next night Dresel slept undisturbed.

Restless-legs syndrome is one of a set of parasomnias known as non-REM sleep parasomnias. They include sleepwalking, sleep terrors, and other "confusional arousals." Another non-REM disorder first described by Schenk and Mahowald, epic-dream disorder, almost always affects women: They dream nonstop of walking through mud or snow and wake exhausted.

If RBD suggests a mixture of REM sleep and waking states, confusional arousals are a mixture of non-REM sleep and waking states. A third disorder recently described by Schenk and Mahowald is status dissociatus, or "brain-in-a-blender." In this condition, Schenk explains, "basically all the major stages of sleep and wakefulness are intermixed." A polygraph on a patient suffering from this condition, commonly limited to chronic inebriates and people with unrelated brain disorders, will exhibit features of REM and non-REM sleep and wakefulness all at the same time. They spend their nights awake and asleep simultaneously--and they look it: twitching, jerking, dreaming, moaning, and speaking.

Observing these mixed states has led Mahowald and Schenk to a theory of brain states as simple as it is radical: that we cycle in and out of sleep and wakefulness constantly. In fact, we're never really completely awake or asleep. "It's very likely that dreamlike activity is going on continuously in both wake and sleep states," explains Mahowald. "During wakefulness our brains are paying attention to externally generated stimulation that suppresses awareness of dreamlike [thought]. When we lose external stimulation, when our brain does not or can not pay attention to it, the only thing the brain has to deal with is the spontaneously generated internal activity.

"Someone made the analogy: The stars are there all the time--during the daylight, and at night. It's just that we can't see them during the daytime. They are lost because of the intensity of the sunlight. Likewise, it may be that brain activity is going on, and we just can't pay attention to it."

Coy Replogle neveronce questioned his own sanity, and the first place he went for help was a sleep lab. In that, he's lucky. Many RBD patients find their way to HCMC after other doctors have given them wild diagnoses like "repressed aggression" or "familial alcoholic personality disorder." Until recent years, the medical establishment considered the parasomnias evidence of major psychiatric disturbance.

"Well, we started seeing adult after adult with terrible sleepwalking and sleep terrors," Mahowald says. "By observation, they did not appear to have any significant psychiatric problems. We undertook a systematic study. We had very detailed neurological and psychiatric and psychological studies completed on all these individuals, and in fact discovered that we had all been taught wrong. We found very little evidence of psychiatric disease. In fact, the most important determinant for being able to have a disorder of arousal is a positive family history."

Science has been slow to accept the idea that dreams are a function of genetics, not of psychoses--chemicals and electricity in the brain, not psychological problems. Indeed, there was a time when all these brain-based theories of dreaming were heretical.

For the past 100 years or so, the theories of Sigmund Freud have held sway (and in some quarters, still do). Freud held that dreams are the "royal road" to the unconscious, the inner self. Somewhere inside us, he theorized, is a primitive, instinctual self: our subconscious. During the day we repress the desires of this inner self. But at night these wishes (sexual and/or murderous more often than not) come out in our dreams (albeit disguised because, even asleep, they are too disgusting to face).

Some of the early brain-based explanations for sleep were just as erroneous. One physiologist suggested sleep was caused by a retreat of blood into the veins. Others have believed that our brain cells become saturated with water, that "sleep toxins" build up over the course of a day, or that some neurological sleep center regulated the entire process. Hundreds of theories like these have been proven false--a fact worth remembering when considering the current theories.

The stumbling block for all these ideas about sleep and dreams, Freud's included, is a lack of physical evidence. In fact, some of Freud's modern critics go so far as to say he deliberately ignored physiology to protect his theory from advances in neurobiology. You can't spend much time in a sleep-disorders clinic and keep up any faith in Freud.

"I think that the whole Freudian concept of dreams is on its way out fast," Mahowald growls. "Real fast. As well it should be. There's no science in it at all. We've seen our dogs and cats dream. Plainly our cats are not resolving deep psychological issues. Add the fact that in utero almost the entire existence is REM sleep; the fetus is probably not dealing with a bunch of psychologically significant stuff.

"Sleep is of the brain and for the brain," he continues. "The only part of the body that benefits from sleep is the brain. In fact, it's one of the most important functions of the brain. It's clearly a neurological function."

Freud and psychoanalysis are being replaced by a sort of old-fashioned, "natural history" approach: Scientists observe natural phenomena, describe them, and draw inferences from their observations. Some scientists maintain dreams are utterly random: fantasy nonsense the higher brain creates, trying to make sense of the bursts of emotion, motion, and vision we experience as we sleep. Others wonder if dreaming serves a purpose, either preparing us for tomorrow or restoring us from today.

One of the more controversial theories is posed by Harvard psychiatrist J. Allan Hobson, who argues that dreaming is delirium. Portions of Hobson's work are untested, but he is immensely influential. Like Mahowald and Schenk, Hobson maintains that our brain states are always in flux. The chemical soup in our heads is boiling one minute, simmering the next--dreaming one minute, awake the next.

Mahowald figures dreaming gives our brains a workout. "If we don't use certain circuits in our brain for a long time they will change function," he says. "If you blind very young animals and keep them blind through an important part of the development of the visual portion of the brain, then un-blind them, they remain blind. So the nervous system requires appropriate stimulation at appropriate times; the integrity and working properties of the brain are dependent upon its being used frequently enough and intensively enough so these neural pathways remain functioning. So the most important function of sleep is a systems activation, if you will, where the brain systematically activates all necessary neural circuits and networks to keep them functioning at peak performance."

In other words, when we sleep, the brain shuts down the body, and one by one blasts the dust out of each of its functions: vision, emotion, etc.

Hobson takes this idea another step: Dreaming, sleeping, and wakefulness are no different than, say, paranoid schizophrenia or being in love. In other words, our very consciousness is a product of the chemical soup and the neuron electrical storm in our skulls. Or, as philosopher John Searle, the author of The Mystery of Consciousness, writes, "Everything in our conscious life, from feeling pains, tickles, and itches to--pick your favorite--feeling the angst of postindustrial man under late capitalism or experiencing the ecstasy of skiing in deep powder--is caused by brain processes."

It's an idea slowly creeping into the mainstream and it's at least as radical as the belief that we are controlled by our genes. It seems a given that eventually doctors will invent a drug that can replacethe feeling of the angst of postindustrial man under late capitalism with the ecstasy of skiing in deep powder.

It's Tuesday,the day staff at the sleep center gather around a conference table to eat sandwiches and chips and trade interesting cases and stories. Sitting around the table are experts in a range of fields: adult and child psychiatry, neurology, pediatrics, pulmonary medicine, and ear, nose, and throat. "These meetings are incredibly educational," Mahowald says. "We learn things every week that you'll never learn in books." They are also a step back from the unending rounds with thousands of patients, from the grind of overnight lab shifts--the humdrum sleep deprivation associated with a modern, public clinic.

Mahowald, slouched behind a deep stack of charts, calls the meeting to order. He runs through a half-dozen patients, most of them suffering sleep apnea or narcolepsy, checking in with the nurses for updates.

Then, a young pediatrician brings up a new patient, a child he discovered on his rounds at the children's hospital who is suffering from severe sleep terrors. Sleep terrors usually strike at the onset of sleep. Victims wake screaming, yet typically remember nothing of the dream that set off the panic.

This child, the doctor says, has persistent, nightly sleep terrors lasting up to an hour. A collective gasp escapes the group. Her father yells at her, trying to wake her up. (Groans.) Her mom picks her up, takes her into the bathroom, and puts a cold washcloth on her forehead in an attempt to make her more comfortable. A few nights ago, the child sat shaking in bed for three hours.

Mahowald's face is creased from doctors' hours. He's chronically hoarse, and speaks in a low voice. He is seldom without a full mug of coffee. For a sleep doctor, he appears tired. "You've got to get her on something that works right away," he says, naming a few medicines that might do the job. "Anything to stop the symptoms. Then you can sort out what might be going on later." It could be genuine sleep terrors, he says, or it could be a nighttime seizure. Lab observation should provide an answer.

The story is a grim reminder of the practical realities in the sleep center: The only theories worth considering are those that work. It isn't that he's not interested in the bigger theoretical questions, Schenk explains. "It's on my list, but I'm not there yet," he says. "I still have a backlog of 20 articles [to write] just describing the parasomnias and their treatments."

At the same time, this focus on clinical practice is one of the real strengths of the HCMC center. "This is the only hospital in the state whose charge it is to take care of anyone who walks in the door regardless of whether they can pay or not," notes Mahowald. "So right away that picks out a certain sort of individual." One who, like Mahowald, has a practical mind: "This is not an esoteric branch of medicine where you identify strange and beautiful things and you can't do anything about it," he says. "The overwhelming majority of people with sleep disorders--be it insomnia, hypersomnia, parasomnia--have something that is very bothersome to them, but it's diagnosable and treatable."

Nonetheless, daily contact with patients and their complaints has a theoretical value, too. It gives HCMC doctors a clear and constant look into the heads of living dreamers. The smartest theoretician couldn't diagnose RBD sitting in an armchair. And now that Mahowald and his staff have described the condition, it forms a critical piece of evidence for the sleep theorists.

These are, to say the least, exciting times at the HCMC sleep center. Much of the credit goes to Mahowald, who co-founded the clinic 20 years ago so he wouldn't have to send patients with sleep disorders to hospitals on one of the coasts for treatment. "We actually worried about what would happen when we identified the 10 narcoleptics and the 10 apneacs in town," he says. "Back then nobody had a clue as to the prevalence of these disorders."

Today the HCMC clinic is one of half a dozen in the state, and even so sees more than 1,000 patients with apnea and nearly as many narcoleptics, plus hundreds of patients with parasomnias. Mahowald and his staff publish probably more scholarly papers on sleep disorders than any other clinic in the country. Television appearances and newspaper interviews are a monthly occurrence.

The Tuesday staff meeting breaks up. Doctors, nurses, and interns drift off to meet with patients. Several filter upstairs to the sleep lab, where a half-dozen new clients are checking in. The patients sit in the lobby, waiting to be hooked up to the machines, to sleep, and to dream.

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