Vladimir Nabokov

NABOKV-L post 0007527, Mon, 3 Feb 2003 22:08:42 -0800

Subject
=== sleep disorders & TRANSPARENT THINGS === (fwd)
Date
Body
From: Thomas Bolt <t@tbolt.com>

Hugh Person's malady.


~ Tom

===================================
The Man Who Mistook His Wife for a Deer

February 2, 2003
By CHIP BROWN


The Strange and the Beautiful

It takes a while to figure out why Dr. Mark Mahowald's
grainy sleep-lab videos are so spooky. One immediate reason
is the phenomena on the footage -- a class of disorders
called ''parasomnias,'' which are defined as unwanted and
involuntary behaviors during sleep and are by definition
occult, because they appear when most people are unable to
witness them. But even the scientists who stay up late by
profession never quite get used to what they see. Mahowald,
a neurology professor at the University of Minnesota and
director of the Minnesota Regional Sleep Disorders Center,
likes to say to his students, ''We study the strange and
the beautiful.''

To judge from the tapes, that's the understatement of the
semester.

Here's a bearded elder man bolting up at 4:30 a.m. He
clutches his left leg, waves his right arm and brays at the
top of his lungs -- "HO! HO! HO!" -- dementedly jolly cries
that also evoke something bestial and wounded. In the
morning he remembers nothing of this ''confusional
arousal'' triggered by obstructive sleep apnea, a condition
in which a constriction of the throat causes you to gasp
for breath. Inevitably the man came to be known at the lab
as Santa Claus. Mahowald said that when the patient saw
himself on tape he was ''horrified'' but finally understood
why he'd been kicked out of so many hotels.

Here's a fat, frizzy-haired woman in bed grinding her
teeth. The sound is like a door hinge in a haunted house.
Her left hand fumbles for a snack; she starts to eat, with
no conscious control over her actions.

Here are people in the midst of ''partial'' arousals who
spring from bed and rip off the electrodes glued to their
heads, removing patches of their scalps as well; people who
box the air, flail at imaginary snakes, twitch, jerk,
groan, rub their genitals, bloody their hands on
nightstands or rock and tremble like bobble-head dolls.
People who by day are wry, levelheaded paragons of mental
health but who at night find themselves locked in
life-and-death struggles with intruders.

Mel Abel, for instance. He's a droll, mild-mannered man who
grew up on a farm in Minnesota, owned a tavern for a while
and sold real estate. A taped snippet of one of his nights
in the sleep lab is part of a parasomnia training video. At
4:24 a.m., Mel begins sleep-talking: ''Quit using the
goddamn bowl for banging like that -- quit it now! Get the
hell out of here! Go on! That's about four times this
morning that I have told you. I don't know if you're that
deaf or that dumb, which . . . goddamn continuously. . . .
What the hell are you looking for, a walleye?''

For sure, some of these spectacles are hilarious. It's hard
not to laugh when a sane Midwesterner who doesn't have a
cat sits on the edge of his bed asleep, saying, ''Here,
kitty, kitty, kitty.'' But it's not so funny if you are one
of the automatons eating raw bacon and cigarettes. Some
parasomnia cases have the parameters of Greek tragedy. Mel
Abel's eyes brim with tears when he tells how criminally
close he came to harming his wife, Harriet. He was
struggling with a deer whose neck he was trying to snap
when he discovered he was actually home in bed with his
hands on Harriet's head and chin. Harriet woke him up,
hollering, ''Mel, what in the world are you trying to do?''


These after-hours manifestations of the strange and
beautiful undermine all our noonday notions of who we are
and what we can command. Suddenly it's easy to understand
what spawned the lore of demons and succubi, those ''old
hags'' from whom the word nightmare is derived, and the
countless other psychoreligious confabulations dreamed up
over the centuries since Plato declared that ''in all of
us, even good men, there is a lawless wild-beast nature
which peers out in sleep.''

Our ideas about ourselves are constantly evolving, but the
pace of the revisions lately has been accelerated by
phenomenal advances in both neuroscience and sleep
medicine, which is one of the youngest sciences. ''We are
at the dawn of the golden age of sleep research,'' says
David Dinges, chief of the division of sleep and
chronobiology in the department of psychiatry at the
University of Pennsylvania. ''The field is moving so fast
scientifically that few researchers can even take the time
to write a book.''

New data about parasomnias are emerging in the context of a
''folk psychology'' that has been shaped by a century of
Freudian opinion. If we now conceive of demons and their
ilk as repressed conflicts and developmental traumas and
accept as axiomatic that the self is not limited to what we
are strictly conscious of even when fully awake, we also
suppose our behaviors are pregnant with hidden meanings and
that our psyches speak in codes only $200-an-hour
masterminds can crack. We suppose hidden truths are waiting
to surface when the guard of waking is dropped.

Parasomnias are interesting for the ways they undercut
these contentions -- for what they imply about the scope
and nature of the self. They point toward a novel model of
the mind that envisions waking, sleeping and dreaming as
distinct neurodynamic states that lie along a continuum and
are separated by imperfect, sometimes porous boundaries.
States can get ''dissociated'' or mixed together in the way
script from one program can hang up in another when you're
shifting between the windows of a buggy computer. If this
''state dissociation'' model proposes a brave new world
shorn of some of our most cozy truisms, it also raises
those questions that inevitably trail after radical
revisions: that's to say, who are we now under these
strange new terms, and how should we live?

Drama Queens

It's probably safe to say that as long as people have been
sleeping they have been having problems sleeping, but the
consensus now is that things have never been worse.
Electric lights, night shifts, double espressos, after-dark
distractions, even the archetype of the macho workaholic
have combined to murder sleep. Millions of Americans have
what is called ''sleep debt,'' which preliminary studies
indicate may lead to heart disease, stroke, diabetes and
depression, among other troubles.

For about 40 million Americans, sleeping woes can be linked
to at least one of the 84 official sleep disorders, the
most common of which are chronic insomnia and obstructive
sleep apnea. People with sleep apnea can wake up hundreds
of times a night and not know it. On the other hand,
parasomnias, which account for about 10 percent of sleep
disorders, are the drama queens of the night, known if not
to the afflicted players (who are by definition asleep)
then certainly to their boggled bed partners. They are
generally divided into two categories that reflect the now
canonical states of the sleeping brain -- those that occur
in Rapid Eye Movement (REM) sleep and those that arise from
non-REM (NREM) sleep.

The most common NREM parasomnias, sleepwalking and sleep
terrors, are often triggered by so-called partial or
confusional arousals from the deepest stages of sleep. Some
stimulus like a loud noise or a full bladder half-wakes you
up, and you have enough awareness to perform fairly complex
motor behaviors -- enough to drive a car, say, or turn on a
microwave -- but not enough to be considered the agent of
your actions by traditional standards. The amnesia
characteristic of NREM arousals seems almost incredible in
the case of sleep terrors, where people will often bolt up
bug-eyed, screaming like actresses in straight-to-video
horror movies. It's no wonder that the prevailing opinion
until recently was that these disorders signaled some
seriously loose screws.

''We were taught in medical school in the 60's that
sleepwalking and sleep terrors in adults were associated
with significant underlying psychiatric disease,'' Mahowald
told me. ''I actually taught that because that's what the
book said. Then we saw a lot of adults with sleepwalking
and sleep terrors who were perfectly well wired
neurologically and psychiatrically. People just didn't want
to believe that a perfectly normal adult could have sleep
terrors and sleepwalking.''

Sleepwalking and sleep terrors are so common among children
between the ages of 4 and 12 that they're considered normal
developmental behavior. It's one measure of how culture is
imposed on us that what's normal in children is problematic
in adults. Often sleepwalkers, or people with some of the
other disorders like sleep-talking, sleep-groaning or
periodic limb movement disorder, don't seek treatment until
they're planning to head off to college or join the Army
and are faced with the prospect of exhibiting their
embarrassing night life in a dorm or a barracks.

The first window for REM parasomnias opens with the initial
phase of sleep associated with vivid dreams. Rapid Eye
Movement sleep could just as easily be named after one of
its other features, muscle paralysis, or atonia, which is
what prevents you from sitting up in a dream to pet a cat
you don't have. The presence of muscle tone is a key to REM
behavior disorder, perhaps the most significant of all the
parasomnias.

The mystery of the brain's nightly oscillations between REM
and NREM is part of the larger enigma of sleep itself. No
one really knows why we have to throw ourselves onto a
pallet every evening, or why the average person spends
about 25 years of his or her life sleeping (or trying to
sleep). All that's certain is that sleep is essential for
many species of birds and for all mammals, and that
evolution seems to have taken pains to keep it in the
picture. (Dolphins, for example, would drown if they
couldn't stay awake to regulate their respiration, but
their brains have evolved the ingenious ability to sleep
one hemisphere at a time.)

Much of what is known about parasomnias has been gathered
in sleep clinics, the first of which was established only
in 1970 at Stanford University. There are now hundreds of
clinics in the United States. When an especially baffling
parasomnia case appears, doctors sometimes refer patients
to top centers like the Minnesota Regional Sleep Disorders
Center, where Mark Mahowald and his colleague Carlos
Schenck have been mapping this esoteric patch of the
mind-body problem for more than 20 years. Late last summer
Mahowald invited me to visit the Minnesota clinic, and
Schenck, a psychiatrist on staff there, offered to
introduce me to some of his patients -- a group of
Midwesterners who were more intimately acquainted with the
strange and beautiful than they'd ever bargained for.

"Nine Years of Hell"

In 1979, after 33 years of marriage,
Rowena Pope thought she knew her husband, Cal, as well as
any soul mate could. They lived in a house in a northern
suburb of Minneapolis. They had raised six daughters and a
son. They had started out ''poor as Job's turkey,'' as
Rowena put it, but had worked hard, Cal as a customs
broker, and Rowena in jobs at a local newspaper, a law
office and the municipal court. She could finish her
husband's sentences and start a lot of them, too, because
he was a man of few words -- dutiful, undemonstrative, slow
to anger, gentle.

''He's part of that generation of men who came home from
World War II, took off the uniform and never said a word
about it to anybody, and anybody who did say a word was a
blowhard,'' Rowena told me when I visited them at their
house.

One spring night in 1979, asleep in bed, she woke up to
find herself under attack. It was Cal, of all people. ''He
was violently kicking and pummeling me and carrying on,''
she recalled. ''His feet were just like hammers -- bang!
bang! bang! It lasted about a minute but it seemed like
forever. He was asleep. I asked him when he woke up, 'What
in the world is happening?' And he said, 'I don't know.'''

She was angry and frightened, but mostly puzzled.

When
he came home from work that night, he said he finally
figured out that he had been having a dream and in it, an
intruder had come into their bedroom and he was trying to
drive him out.

''That was the beginning of nine years of hell,'' Rowena
said.

Night after night, Cal would kick and shout in his sleep.
The episodes began to take a toll on the house, not to
mention on Cal's body. He knocked pictures off the wall. A
head butt left a crack in a walnut dresser that had
belonged to Rowena's mother. He threw a punch that put a
crater in the plaster bedside wall. He cracked a toe, and
bloodied his knuckles more times than anybody could count.

The episodes also began to take an emotional toll on
Rowena. ''There was never a time when we were free of it,''
she said. ''We turned down invitations to stay overnight at
friends' houses. Cal never wanted to travel. At night he
would be shouting and cavorting and carrying on. I finally
said, 'You have to sleep in another room.' I talked to our
family doctor, and he said, 'Oh, it might be something he
ate.' People didn't know anything about this.''

She thought maybe Cal had post-traumatic stress from the
horrors of his experience in the war. What was most
exasperating was that Cal didn't think he really had a
problem. When he was dreaming he lacked any awareness of
being in a dream, and when he would wake up, he had little
if any memory of what had happened. Because his sleep was
chopped up with so many arousals, he was often exhausted
during the day and would come home from work and collapse.

''I just figured I was working too hard,'' he said.


''Sometimes he would shout out in his sleep 'No! No! No!'''
Rowena said. ''I had never heard him sound so anguished
before in my life. It was heart-rending. He's never been in
a fight as far as I'm aware of. He was never jealous.''

They took all the framed pictures out of the room. They got
a bed that was low to the floor and under the carpet laid a
double-thick pad to cushion the falls Cal might take.

A feeling of estrangement crept over their marriage. Cal
eventually moved all his clothes and belongings into
another room. Sleeping in separate beds was ''abhorrent''
to Rowena, but she felt there was no choice.

Then one afternoon she saw a report on the local TV news
about a man who mistook his wife for a deer. It was Mel
Abel. Rowena tried to persuade Cal to have an evaluation.
He resisted, even though the behavior seemed to be getting
worse. She recalled one incident in an account she wrote
up:

''One afternoon while he was napping on the couch as I read
a book, he played out a scene more awful than anything I
had ever seen or heard. He rolled off the couch and hit the
floor. Normally, a fall to the floor would have awakened
him. But instead he began roaring like a wounded wild
animal. I sat in my chair frozen with fear as I watched the
unbelievable scene unfold. He roared, he crouched, he
pounced and finally crawled into a space between the couch
and the wall, as if in a den or lair. When I was able to
speak I shouted to awaken him. He could not believe my
description of what had just happened, even though he was
surprised to find himself on the floor.''

Rowena had finally had enough. She wrote to the Minnesota
sleep center and in November 1988 got Cal an appointment
with Dr. Schenck. The next month he spent two nights in the
sleep lab. The diagnosis was indeed what Mel Abel's had
been: REM behavior disorder.

''It was such a relief to get a diagnosis and treatment,''
Rowena said. ''At the time they had only diagnosed 25
people.''

Only two years earlier in the journal Sleep, Mahowald and
Schenck had published what would come to be considered one
of the seminal papers in the field, formally identifying
REM behavior disorder (R.B.D.) as a new parasomnia. R.B.D.
mainly affects men over 50 and is characterized clinically
by changes in the nature and range of a patient's dreams,
as well as by a spectacular loss of the muscle paralysis
that prevents most people from acting their dreams out.

In a way, REM behavior disorder is the mirror image of
narcolepsy, the well-known disorder that can cause people
to nod out in the middle of a sentence. In narcolepsy, a
feature of REM sleep (muscle atonia) intrudes into waking.
In REM behavior disorder, a feature of waking (muscle tone)
intrudes into REM sleep. A sedative, clonazepam, which
works in ways nobody really understands, has been proved an
effective treatment for REM behavior disorder. It doesn't
restore the muscle paralysis but seems to calm the brain
down enough to keep the dreamers in their beds.

What makes REM behavior disorder so theatrical is not just
the dream enactment but also the change in the character of
the dreams. They become more like pulp fiction, filled with
intruders, obscenities, kicks and uppercuts. Here, you
might think, is a psychologically rich parasomnia in which
the sleeping mind betrays the unexpurgated feelings hidden
behind the mask of civility.

Apparently not.

''The R.B.D. behaviors and their associated stereotypic
dream changes are the most reflexive by-products of altered
brain-stem activity,'' Schenck told me. ''They are
behavioral storms coming from the brain stem.''

In Schenck and Mahowald's view, what argues for the finding
that R.B.D. behavior has little if anything to do with
psychodynamic factors are the famous experiments with cats
that anticipated the discovery of REM behavior disorder in
humans. Michel Jouvet and his colleagues in France in the
1960's made lesions in cat brain stems that prevented
muscle atonia. When the cats went into REM sleep, they
didn't lie immobilized in the dream world; they scrambled
up, arched their backs and acted out all sorts of
aggressive automatic behaviors.

''The categories of behavior seen in REM-behavior-disorder
patients are the exact same categories seen in animals,''
Schenck said. ''We see simple jerking and twitching,
orientation responses, locomotion and violent behaviors. We
don't see feeding, eating, grooming or sexual behavior.
Basically, with REM behavior disorder your dream content
gets very restricted. Everything is shunted along certain
pathways. A lot of people say after treatment, 'I can have
my regular dreams again!'''

One of Schenck and Mahowald's most remarkable findings was
that in 65 percent of their male patients over 50 (without
a neurological condition), the onset of REM behavior
disorder proved to be a harbinger of Parkinson's disease.
Some patients actually experienced changes in the content
of their dreams months before they began acting them out.
In those who developed Parkinson's, symptoms of the disease
appeared within 13 years on average from the onset of
R.B.D.

Schenck and Mahowald identified R.B.D., but they were not
the first to describe the behavior, as Schenck learned in
December 1996, when he flew to Madrid to give some talks to
a Spanish neurological society. At dinner one night, two of
his colleagues presented him with a gift, a copy of Miguel
de Cervantes's epic novel ''Don Quixote,'' published in
1605. A passage was marked on Page 364. Schenck, who speaks
Spanish, began to smile as he read Cervantes's lines: ''He
was thrusting his sword in all directions, speaking out
loud as if he were actually fighting a giant. And the
strange thing was that he did not have his eyes open,
because he was asleep and dreaming that he was battling the
giant. . . . He had stabbed the wine skins so many times,
believing that he was stabbing the giant, that the entire
room was filled with wine.'' A classic case of R.B.D.,
described 381 years before the condition was recognized.

Cal Pope still thrashes in his sleep, but his medication
has managed the behavior fairly well for 14 years now, and
some good things have come back into his and Rowena's lives
-- not everything, but Rowena prefers to count her
blessings. After 56 years of marriage, she has the company
of her husband again, not that wild beast that was peering
out at her from sleep. They go to the movies once a week.
Evenings at home they watch the news together, sometimes
sharing a bowl of popcorn or ice cream, and then around 10,
still a little wary of the night, they head off to separate
rooms.

"Even the Mice Have Left"

Because people have been devising theories about the
meaning of dreams for centuries, convinced that dreams are
messages from God or postcards from the unconscious or
telepathic communiques from the great beyond, it's hard to
imagine that a sleep disorder involving dreams could reveal
so little about an individual's psyche. But this is what
sleep scientists argue is the case. As Schenck noted, in
both REM and NREM parasomnias, more than 90 percent of the
wild stuff recorded in the sleep lab are ''automatic
behaviors related to neuronal activity and/or abnormal or
confusional interactions with the immediate environment.''
In the more relaxed setting of the home, he says, there is
a slight increase in what he termed ''psychologically
meaningful'' behaviors for people with NREM disorders like
sleepwalking and sleep terrors and, to a lesser degree,
sleep-related eating disorder. For those with REM behavior
disorder, however, being at home makes virtually no
difference.

''In the lab, what we see a little more of aren't really
'deep-seated' psychological behaviors dealing with
neurosis,'' Schenck said. ''They're more things like a
mother searching for her baby and picking her baby up for
fear the baby may not be safe.''

Maureen Strehlow, a 57-year-old woman with dark brown eyes
and hair, lives alone south of Minneapolis. It has been 10
years since she first walked into the Minnesota Regional
Sleep Disorders Center. At that time, she had been divorced
a few years; she was living with her three children, and
she was at her wit's end.

She had discovered that she was powerless to stop eating in
her sleep -- sleep, or whatever that twilight state was in
which she would traverse the hall from the bed to the
kitchen, usually with no recollection in the morning but
aware enough at the time to rummage in the counter drawer
for the stale licorice behind the coffee filters. The list
of tactics that failed to thwart her behavior was long. She
had tried to ''prime'' herself not to eat. She'd hung paper
plates block-lettered with the word ''EAT'' with a bold
slash through it. She had even hired one of her daughters
at a few dollars a night to bed down in the hall outside
Maureen's room on the theory that the teenager might be
alert enough to intervene, or at least present an obstacle.


''You know how kids sleep,'' Maureen recalled. ''A
bulldozer could hit the house and they wouldn't wake up.
The first night I stepped right over her.''

Maureen got rid of the sweets she usually went for, but
then she discovered one morning that she had opened a can
of soup and picked out the mushrooms.

She was so tired in the morning she would hit the snooze
alarm six times. What bothered her more than the fatigue
and the lack of control was how she was ruining her figure.
For a while, she had a helpful adversary in her youngest
daughter, Suzanne.

''Five or six times Suzanne heard me get up in the night
and came running upstairs from the basement. She would
stand there with her hands on her hips and say, 'You're
eating!' And I'd say, 'I'm not eating!' And she'd say:
'Duh! You are too!' Part of me was mad at her. And then in
the morning, if I hadn't eaten, I'd be so grateful.
Sometimes I was totally asleep; other times I had some
awareness. I would say 75 percent of the time when I woke
up in the morning I'd have no memory of getting up and
eating. But then something might jog me and I'd remember.''


She had been eating in her sleep since her late teens,
finding clues like chocolate frosting on her pillow or
cherry pits and porkchop bones in the sheets. ''I thought I
was the only person in the world doing this. I would wake
up in the morning wondering, What did you do last night?''

In 1992, a friend was listening to a radio program that
featured Carlos Schenck talking about people who eat in
their sleep. There had been scattered case reports of
nocturnal eating in the medical literature going back to
the 1940's, but in 1991, again in the journal Sleep,
Schenck and Mahowald described 19 cases of what they were
formally introducing as sleep-related eating disorder
(S.R.E.D.).

''My friend called me at home,'' Maureen recalled. ''She
said, 'This is you!' I called the center the next day.''

Her condition was diagnosed as S.R.E.D., which is defined
as compulsive eating occurring during partial arousals from
NREM sleep. It often combines elements of an eating
disorder, which is considered a psychiatric condition, with
elements of a sleep disorder, which in Maureen's case
researchers speculate is related to a deficiency of
dopamine in her brain.

''No matter how it begins, either with stress or with
another sleep disorder such as sleepwalking, sleep-related
eating will usually become a nightly phenomenon,'' Schenck
told me. ''The one variable is the level of consciousness
associated with the eating. Usually there is partial
consciousness, but in about a quarter of our patients there
can be complete unconsciousness, and in about 15 to 20
percent of cases, there is full wakefulness and subsequent
recall, but no control over the eating.''

Schenck prescribed Maureen a dopamine-enhancing medication
and Tylenol 3, which contains codeine.

''When I first started taking the medications, I was
running around the neighborhood singing Hallelujah!''
Maureen recalled. ''I felt so good about myself. I started
exercising. I would call up guys and ask them out to
dinner.''

For three years her sleep-eating was well controlled by the
prescriptions. But then what Schenck believes is an
underlying condition emerged -- the sleep disorder known as
restless legs syndrome, which is characterized by extremely
painful crawling sensations in the legs.

When I visited in October, Maureen had recently had a
relapse of sleep-eating, and her restless legs syndrome was
acting up. ''It's kind of depressing what I can do,'' she
said, with a rueful laugh. ''Last week I woke up with the
worst taste in my mouth -- I had made a sandwich out of
beef-bouillon cubes in my sleep. Who'd eat that? It's
probably because there's nothing to eat in the house. Even
the mice have left.''

She showed me the route from her Victorian bed to her
tan-tiled kitchen. The way was lined with potential
obstacles -- her collection of large crocks, a rocking
horse, a congress of teddy bears, breadboxes, ceramic
pitchers -- all of which she always managed to negotiate in
her sleep. When she was married, she said, she lived for a
while with her mother-in-law, who was fighting cancer. She
had loved her mother-in-law, and it still baffled and upset
her that she could get up night after night to eat but
never once think to check on the woman dying in the next
room.

Cat Boy

The treatment Maureen Strehlow received for the pain in her
legs and for her sleep-eating never addressed the
possibility that psychological factors might be
contributing to the disorders. No one would think to look
for psychological factors in restless legs syndrome. But
with sleep-eating, despite its automatic quality, the role
of the psyche is harder to rule out. People recoil from a
strictly neurological view of behavior basic to their
identity -- behaviors related to food, sex, emotions,
language and even dreams -- despite the obvious distortion
of dreams in REM behavior disorder.

If there was an emotional or mental cause to Maureen's
sleep-related eating, something other than the varying
dopamine levels in her brain, she wasn't aware of it. The
persistence of the behavior over the years had disabused
her of the idea that she could do much to curb her trips to
the kitchen; it was more important to her to break the
pattern than to hunt for psychological origins under the
iffy assumption that they existed. In any case, she didn't
expect uncovering them would make any difference.

While skepticism about psychological causes ought to be
routine, given how wantonly they've been applied to
conditions where they had no business, sometimes there is
no recourse but to invoke the psyche as the source of a
parasomnia. One of the more startling episodes captured on
tape at the Minnesota clinic is the nocturnal behavior of a
19-year-old known in the lab as Cat Boy. Fifty-three
minutes after falling asleep, the teenager gets out of bed
and begins crawling on the floor, growling, his hands
folded into paws. He seizes a corner of the mattress with
his teeth and shakes it. After six and a half minutes,
perspiring heavily, he collapses and becomes ''clinically
unresponsive.'' When technicians ask him, he reports that
he has been dreaming what he always dreams -- he is a large
cat following a female zookeeper with a bucket of raw meat.
Here's the strangest thing of all: this parasomnia is not
technically a sleep disorder. Throughout the episode Cat
Boy's EEG reports that his brain is ''awake.''

In his case, the diagnosis was of a psychiatric condition
that happened to reveal itself under cover of darkness.
Researchers at the Minnesota clinic estimate that about 7
percent of their parasomnia cases are actually nocturnal
dissociative disorders. And these disorders consist of
almost nothing but psychologically meaningful behavior.

''The behaviors reflect the psyche and past psychological
experience usually in the context of physical, sexual,
verbal abuse,'' Schenck noted. ''Many of the observed and
recorded behaviors, including vocalizations (moaning and
words), are a combination of sexual and sexualized
behaviors -- pelvic movements and thrusting -- and
defensive behaviors and vocalizations, like 'No, no, no,
don't do that!' or 'You're hurting me!' or 'Stop! Stop!'
The EEG is awake but the person (usually female) perceives
her dissociated memory of past abuse as an actual dream, as
if she were asleep even though she is technically awake.''

Even to a tutored eye, it is impossible to distinguish
between behavior arising from a sleep disorder and behavior
arising from a nocturnal dissociative disorder without a
work-up in a sleep lab. For all their resemblance,
parasomnias from the sleep state and parasomnias emerging
from waking-state dissociations belong to different domains
with different moral expectations. Cat Boy's parents were
upset to learn his condition was a psychiatric disorder.
The finding put the onus not on the body but on the mind --
on the waking state with its apparently defective
self-control rather than on the sleep state where custom
accepts that the self will vanish into the automatism of
the brain.

The expectation that we ought to be able to control
ourselves is essentially the issue at stake in criminal
cases. Sleepwalking has been successfully used as a legal
defense in some homicide cases but has failed in others.
The main hurdle is that experts cannot determine the actual
state of the brain after the fact, only whether a person
has a propensity for partial arousals.

More mundanely, the premium on self-control heightens the
guilt of people who exhibit sexual behavior while asleep.
''Sleep sex'' is not an officially classified disorder, but
it has been the subject of a much-publicized recent study
by researchers at Stanford University and has been observed
since the inception of overnight sleep-lab studies. ''I got
a call about this from Playboy magazine years ago,''
Mahowald told me. ''Technicians have seen it in the lab for
years. It happens all the time. Most likely it's a
specialized form of sleepwalking.''

Dr. Christian Guilleminault and other scientists at
Stanford's Sleep Disorders Clinic reported on 11 cases of
''atypical sexual behavior'' during sleep. The behaviors
included ''violent masturbation, sexual assaults and
continuous (and loud) sexual vocalizations during sleep.''
Eight of the cases occurred in NREM sleep, three in REM. In
four of the cases no psychopathology was diagnosed. In the
others, a range of psychiatric ailments was found, from
depression to obsessive-compulsive tendencies to anxiety,
but the researchers concluded, ''We do not know to what
extent the psychiatric disorders played a role in the
observed behaviors.''

Psyche vs. Neuron

The Minnesota Regional Sleep Disorders Center is housed on
the eighth floor of the Hennepin County Medical Center in
downtown Minneapolis. It has a wing for offices and
consulting rooms and one for overnight sleep studies, of
which the center does about 1,500 a year. On the afternoon
when Mahowald was running through his parasomnia highlights
reel, a crowd drifted in, Schenck among them. Mahowald and
Schenck have been collaborating for 21 years. They have
co-written 23 textbook chapters and 43 articles in
peer-reviewed journals. They have made major discoveries
and numerous contributions to the field of sleep medicine.

But there are subtle, psyche-versus-neuron differences in
their views, some of which reflect differences in their
training and background. Mahowald, 59, was born, bred and
schooled in Minnesota. As a neurologist, he has a
materialist's innate suspicion of nonmaterial concepts and
explanations. Schenck, 52, is a psychiatrist who grew up on
Manhattan's Upper West Side, where mentalist theories are
as much a part of the landscape as
alternate-side-of-the-street parking.

Even people who had seen the clips previously stared
quietly as the train of strange behaviors flashed by. The
tension in the office wanted breaking. ''We rent these out
on weekends,'' Mahowald said.

A new clip started. ''Here's a sleep terror,'' he
continued. ''You can trigger a sleep terror de novo, from
nothing -- just the sound of a doorbell or a buzzer from a
six-volt battery -- which means it's not a climax of
ongoing dreamlike mentation. See this kid -- he's paying
attention to exogenous and endogenous information. It's not
like a nightmare when you can remember why you are
frightened. In nightmares you have an accelerated heart
rate. With a sleep terror you have no anticipatory increase
in the heart rate.''

A man with REM behavior disorder appeared on the monitor
fighting phantoms over his bed. A case of a person acting
out a dream?

''Either he's acting out a dream, or possibly dreaming out
an act. It could be that the brain makes up something to
explain the movement created by motor-pattern generators in
the brain stem.''

Schenck piped up. ''But isn't there still room for Freud?''
he asked, using ''Freud'' as a synonym not for
psychoanalytic doctrine but for the idea that what's on the
mind can modify what's in the tissue. There was a
deferential note in his voice, as if he knew the suggestion
might irritate his senior colleague. ''One of our R.B.D.
patients after his divorce said he was always dreaming of
an 800-pound gorilla chasing him around the house. How can
you not consider a psychodynamic influence in a scenario
like that, with the man's ex-wife thinly disguised as an
800-pound gorilla?''

Mahowald shrugged. Was he ceding the point? On the screen
now a black Labrador retriever was snoozing on his side.
The dog's legs began pedaling wildly, pawing the air. Was
he inventing a dream to go with the mad scrabbling of his
legs -- perhaps a hot-pursuit sequence involving a mailman?


''I don't know,'' Mahowald said with a happy little drop of
arsenic in his voice, ''but I suspect he's not resolving
deep inner conflict.''

Maybe It's a Gift

Not long ago in an Italian biology journal, Mahowald and
Schenck proposed a ''state dissociation'' model of the
brain. But recently Mahowald told me that he had reviewed a
new book, ''The Dream Drugstore,'' by Allan Hobson, a
Harvard dream researcher, and that Hobson's model,
developed over the last 25 years, was much better than his
own. Hobson's so-called Activation Input Modulation theory
tries to account for waking, sleeping and dreaming, as well
as states like coma, by picturing the mind-brain as a cube.
The three dimensions of Hobson's cube reflect the three key
variables that determine a person's consciousness at any
given moment. The first variable is the level of activation
in the brain; coma, for example, would be at the low end;
waking and vivid dreaming at the high end. The second
variable is the predominant source of input -- in waking,
for instance, the brain's attention is concentrated on the
external environment, but in REM sleep the brain is mostly
minding itself. The third and most complex variable is the
brain's chemical microclimate, the fluctuating mix of the
neuromodulators that can enhance or impede the brain's
ability to analyze information.

''The AIM model says that the brain-mind is constantly
changing states,'' Hobson said when I went up to Boston to
talk to him. ''There are canonical states like sleep and
waking, which we know well and about which we have little
or no choice. They are probably genetically determined and
highly conserved by evolution and tremendously significant.
But there are all kinds of design and program errors that
can happen in any complex system, and that's probably what
accounts for a lot of the parasomnias.''

And where is the self in this enchanted complexity? Hobson
is not one to write it off as a chimera yet: ''The self is
a gorgeous construct, an essential construct that is
capable of making many decisions. You can't tell me it
doesn't matter. People will say to me, 'Oh, well, you're
just as religious as the theists,' and I say, 'O.K., we
might find out that it's all automated, but it sure doesn't
feel that way.'''

In another society Lindsey Conlon might be a healer or a
shaman and her powers of dissociation cultivated on the
trellis of a spiritual tradition. Her gorgeous construct is
grappling with a parasomnia whose very name -- parasomnia
overlap disorder -- attests to the potency of Hobson's
model and the idea that the brilliantly promiscuous brain
can exist in more than one state at once. Here's a portion
of the write-up of Lindsey's first night in the Minnesota
clinic lab in May 2000: ''The study was notable for
numerous spontaneous brief arousals from all stages of
non-REM and REM sleep. . . . Periodic limb movements were
present throughout all stages of sleep, often but not
always associated with arousals from sleep. REM sleep was
characterized by a relative lack of atonia. . . . There was
one episode of sleep-talking.''

''And I know they didn't see the half of it,'' Lindsey told
me in October when we met for dinner at a restaurant in
northwest Minneapolis. ''Who can sleep with that camera on
them?''

Lindsey works as a patient-services coordinator at a local
hospital. She is 24 years old. She has high cheekbones and
lanky brown hair, which she pushes back behind her left ear
but lets hang freely over her right because she doesn't
want people to see the hearing aid she wears in it. She was
born profoundly deaf but has learned to speak with almost
no impairment.

''I remember when I was around 6,'' she said, ''I walked
out of my bedroom into the kitchen, poured a glass of water
and then picked up a stack of serrated computer paper and
pulled the sheets around the living room in a complete
circle. My mother thought I was awake and couldn't
understand what I was doing. I've always sleepwalked. I've
always had conversations with myself. I'll ask myself a
question and answer it. I'm aware I'm doing this but I
can't dissociate enough to tell myself to shut up. But it
never really struck me as a problem.''

But in 1999, on vacation, she was staying with some
girlfriends in an Orlando hotel room. During the night,
Lindsey got up in the middle of a dream, convinced the
group would soon be swallowed in a flood. She paced from
bed to bathroom, imploring her roommates to evacuate.
Finally her friend Jenny woke up.

''What the hell are you doing?'' Jenny said.

''We've got
to get out of here!'' Lindsey said.

''Lindsey, did you take anything?''

''I'm going
outside!''

Jenny managed to get Lindsey back to bed.

Not long after, back in Minneapolis, Lindsey was sleeping
at her boyfriend's house, and she had another partial
arousal.

''I crawled over him, turned on the light, opened his
closet, put on a shirt and went to my purse to get my car
keys. I started talking about how I had to get something
out of the car. The guy woke up, luckily, and lured me back
to bed. My eyes were open the whole time. I was awake at
some level, but it's almost like I had a virtual-reality
headset on. I remember crawling over him, turning on the
light, and him looking at me and saying, 'What the hell are
you doing?' I know I'm doing what I'm doing, but it's like
I can't dissociate enough from the actions to tell myself
to stop. That's what made me nervous. I actually had the
car keys in my hand.''

When she got ''caught'' talking or walking in her sleep,
she invariably felt embarrassed and stupid, she said.
''I've been trying to find a pattern. Is it the moon? Is it
stress? Am I upset about something? I can never correlate
it with anything. Where it comes from, why it happens -- I
don't know.''

Unlike most sleepwalkers, Lindsey is often dreaming while
she walks, and unlike most people with REM behavior
disorder who usually don't get too far from their beds, she
can stray some distance. She has always had hypervivid
dreams and often the sensation of dreaming all night
without interruption, a phenomenon described in sleep
medicine as ''epic dreaming.''

''I had one dream where I was in a war, and I could see the
decals on the planes flying by and the bombs coming out,''
Lindsey said. ''I could feel the ground shaking as they
hit. I was with my family, we were all running away, and I
kept saying, 'We have to keep moving!' It was unbelievably
intense. I know I'm dreaming. I can control some of them.
I'm almost always watching myself. I've watched my own
funeral. I remember walking into church and seeing my
family and realizing it was my funeral, and then walking
around the corner and seeing the casket and it was me lying
in it, and saying: 'No! No! No!' It was more vivid than a
movie.''

She referred herself to the Minnesota clinic and received a
diagnosis of parasomnia overlap disorder -- unwanted
behavior in REM and NREM sleep. Her medication has quelled
the arousals and blanked out her dreams. That's good in
some ways; in other ways it has dulled something in her
that perceived the world in a rare way.

''The good thing is that I'm not always wondering why I
have this condition, or what it symbolizes, or what's going
on in my life that's making it happen,'' she said. ''And my
fiance, Mike, is able to sleep next to me. I take Xanax a
half-hour before bed. I can feel my whole body dropping.
It's like someone hits you on the head. I go right to
sleep. I'm still exhausted during the day, though, and now
I take Adderall to wake up. And I wonder if the drugs are
just masking things. Are they really slowing down my brain
waves or just making it so I don't notice the states I used
to be in.''

She pushed her hair back over her left ear.

''I think I have a different way of looking at things
because I was born deaf,'' she said. ''I think one reason
my dreams might be so vivid is that I depend so much on
vision, and I'm very sensitive to touch.''

And weirdly she was always having deja vu experiences. She
wondered if her easy access to altered states had made her
especially aware of odd synchronicities and the way
dreaming and waking were entwined. When the dream world was
more vivid than the waking one and she was able to move
around inside it, swept up in its matchless enchantment and
creativity, knowing she was dreaming yet able to exert some
measure of her will (except in those moments of horror),
sometimes she wondered whether her condition was a disorder
or a gift.

A White Crow

If it's the case that most parasomnias express nothing more
than the gibberish of a confused brain -- that they have
more to do with genes and physiology than with repressed
conflicts or pathogenic secrets; more to do with the
mechanics of the brain than with trouble on the mind --
it's also true that once in a while a parasomnia can
articulate the essence of a person's life. Some
sleep-related behavior can seem to be permeated with
psychological meaning. Perhaps it can even be caused by
what's on a person's mind. Generally these cases are as
rare as the proverbial white crow. As Mark Mahowald
emphasized: ''The percentage of patients performing
psychologically significant actions is minuscule. I'm not
sure our center has seen a single example.''

But now and then, a white crow turns up. Last September, I
heard about a sighting from Dr. John Winkelman, a
46-year-old assistant professor of psychiatry at Harvard
medical school and a well-known authority on parasomnias.
Winkelman had described how post-traumatic-stress disorder
patients sometimes suffered from insomnia because trauma
had made them hypervigilant. But he had recently seen a
50-year-old woman with post-traumatic-stress disorder whose
complaint was not insomnia but sleepwalking.

When she would stay at her daughter's house, she would get
up, walk to her granddaughter's crib in the nursery, put
her fingers in the baby's mouth and appear to be trying to
clear the girl's airway. Sometimes she would give her
mouth-to-mouth resuscitation. As the baby needed none of
this, the girl's mother was freaked out. ''Although we have
no way of knowing for sure without observing her behavior
in a sleep lab study, the woman was probably sleep-walking
because she had no memory of the behavior,'' Winkelman
said. ''And it was usually happening in the first hour of
sleep. I asked when the behavior started, and she said it
was 10 years ago. I asked if anything had happened around
that time. She said as a matter of fact, yes, she had been
baby-sitting for some parents and had fallen asleep, and
while she was asleep the parents came home and discovered
the baby had died in the crib.''

''So in her sleep she was trying to save the child,'' I
said.

''Or trying to undo the event,'' Winkelman said. ''This is
a meaningful parasomnia. In a way it would be easier to
treat her if we didn't know the story. We could do a
clinical work-up, handle it like a typical case of
sleepwalking. Maybe she had some sleep apnea that was
causing the arousals. We could prescribe some Halcion, and
in a practical sense we would be preventing her from doing
the behavior.''

''But you wouldn't be helping her atone.''

Winkelman
nodded -- humbled, it seemed, by the immense domain of
suffering beyond the bounds of medicine.




Chip Brown is the author of ''Good Morning Midnight: Life
and Death in the Wild,'' which will be published in April
by Riverhead Books.

http://www.nytimes.com/2003/02/02/magazine/02SLEEP.html?ex=1045332667&ei=1&en=6d050023fdfeb754




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