Parkinsons Disease:

Decreased Performance of
Unconscious Processes

Written by Zahraa Hotait

Ms. Bagley
G/T Intern Mentor
January 2017
Zahraa Hotait

Ms. Bagley

G/T Intern Mentor

14 January 2017

Parkinsons Disease: Decreased Performance of Unconscious Processes

In one afternoon, a grandmother with bright pink hair, a retired businessman who

coaches childrens lacrosse leagues, and an avid artist who creates beautiful paintings entered

the same clinic. What do these diverse individuals have in common? They have all been

diagnosed with Parkinsons disease. Parkinsons disease (PD) is a progressive

neurodegenerative disorder affecting over 10 million people worldwide, according the the

Parkinsons Disease Foundation. The disease is one that is relatively familiar to most; many

people will have a grandparent with Parkinsons disease, or will recognize the disorder in

Michael J. Fox, a famous actor-turned-advocate for Parkinsons research. Parkinsons disease

is caused by the degeneration of dopamine neurons, which provokes observable symptoms

once it begins to affect parts of the brain including the substantia nigra and other deep nuclei

of the brain (Sveinbjornsdottir). The symptom that is most easily associated with Parkinsons

disease is the appearance of a resting tremor in the hands, meaning that the shaking motion is

prevalent even when the patients hands are relaxed. The tremor is described as having a

pill-rolling motion, which refers to the distinctive motion of a Parkinsons tremor where the

thumb and index finger approach each other in a slight circular motion. This tremor often

originates and is more severe on one side of the body, as are rigidity and other symptoms.

Bradykinesia is also highly noticeable in Parkinsons patients; voluntary movements are

greatly slowed, and it is more difficult to begin the course of the movement

(Sveinbjornsdottir). Additionally, many factors affecting gait necessitate the use of a walker

or cane for many Parkinsons patients. These include stooping, lack of natural arm swinging
motions, and festination, a condition that causes the patients steps to become increasingly

smaller and faster as they walk. These symptoms often increase the risk of falling for

Parkinsons patients, which heightens the danger associated with the disease; problems that

arise from difficulty balancing and swallowing pose serious risks to a patient

(Sveinbjornsdottir).

However, although the motor symptoms of Parkinsons disease are often the most

well known, distinctive, and diagnosed symptoms, the onset of motor symptoms is often

preceded by as many as ten years by more subtle nonmotor symptoms. For example,

depression, anxiety, REM behavior sleep disorder, nocturia, and constipation are all noted

symptoms of Parkinsons disease (Gurevich and Gurevich). Although the disease is treated

medically with carbidopa-levodopa to replace decreased levels of dopamine resulting from

the degeneration of dopamine neurons, levodopa does not alleviate many of the nonmotor

symptoms of Parkinsons disease (Gurevich and Gurevich). For this reason, medicated

Parkinsons patients still struggle with many aspects of the disorder. The cause of some of

these symptoms (such as drooling) is still unclear, and may be linked to unconscious

processing of stimuli and movements. While many treatments have been developed for

tremor and rigidity, it is less straightforward for healthcare professionals to treat the other

comprehensive set of symptoms. To address this apparent issue, I believe that future

treatment of Parkinsons disease should focus on deterioration in unconscious registration of

stimuli demonstrated by a decrease in natural bodily functions, progressive degeneration

throughout the duration of the disease, and inability to react regularly to unconsciously

processed stimuli.

Firstly, patients with Parkinsons disease have difficulty performing natural

movements, including swallowing. Consequently, one of the easily identifiable symptoms

associated with Parkinsons disease is sialorrhea (Johnson). Sialorrhea, or drooling, can be

defined by an excessive pooling and spillover of saliva out of the oral cavity, and can

greatly affect a patients personal life by causing embarrassment and enhancing other

psychological effects (Srivanitchapoom et al.). However, Parkinsons patients actually exhibit

decreased production of saliva, as demonstrated by multiple studies that measured the saliva

output of two groups of Parkinsons patients: those complaining of drooling, and those

complaining of dry mouth. Despite these opposing symptoms, both groups of patients

ultimately displayed decreased production of saliva as compared to control patients (Bateson

et al.). This poses the question as to why drooling would be present if there is in fact less

saliva in the patients mouth. That is where the decreased ability to swallow plays an

important role; the drooling is not related to the amount of saliva produced, but instead to the

impaired process of swallowing to reduce saliva that accumulates inside the oral cavity.

Patients must focus specifically on this action before they can react appropriately, slowing

their responses (Bateson et al.). Additionally, hypomimia, defined as unintentional mouth

opening and stooped posture with dropped head (Srivanitchapoom et al.), could also

contribute to drooling. The patient may be unable to correctly regulate the posture of their

head without a directed conscious effort, although most people without the disorder are able

to hold their head up appropriately without focusing on the action. This is a clear example of

how the lack of ability to monitor unconscious functions could be central to many

Parkinsons symptoms. Because of the great effect these symptoms have on patients quality

of life, future research concerning treatment plans should be focused on the underlying causes

of these many diseases.

Secondly, Parkinsons disease is a progressive disorder (Sveinbjornsdottir). This

entails that its symptoms progressively worsen after diagnosis; there is no cure for

Parkinsons disease, so the symptoms will not recede, nor will they cease to progress. The

expanse of Parkinsons symptoms, from tremor to balance, will continue to deteriorate

throughout the course of the disorder (Giroux). Often, this requires the patients medication

dosage to be increased. Unfortunately, although large doses of levodopa administered over a

prolonged period of time will continue to reduce tremor, rigidity, and several other symptoms,

they will also cause adverse effects. The most prevalent of these consequences is the

appearance of dyskinesias, which are involuntary movements of the head, torso, or limbs that

are often characterized by a squirming-like quality (Sveinbjornsdottir). Some patients may

qualify for deep brain stimulation, in which systems of electrodes are surgically implanted in

one or both sides of the brain. These systems use electrical impedance to correct the incorrect

impulses sent by degenerated dopaminergic neurons. However, this surgery imposes

additional risks on the patient, and is therefore not the ideal course of treatment (Johnson).

Additionally, medication can also result in enhanced neuropsychiatric symptoms, which

include hallucinations. Therefore, increasing the dose of medication is not always possible,

and the patients symptoms continue to worsen without a course of treatment that can counter

them (Johnson). It is likely that if both motor and nonmotor symptoms of Parkinsons disease

progressively worsen throughout a patients life, the inability of Parkinsons patients to

unconsciously process various stimuli and actions will continue to deteriorate as well. This

means that as the disease progresses, the patient will be increasingly unable to respond

appropriately to functions that should be managed on the unconscious level. Patients may

experience worsening difficulty in swallowing and other functions, which could greatly

impact their overall quality of life and ability to continue a fuller and more independent

lifestyle.

Lastly, patients with Parkinsons disease are not only unable to sufficiently perform

unconsciously regulated functions such as swallowing, but may also be characterized by an

inability to process various sensory stimuli on the unconscious level. This can be investigated

through a phenomenon called masking, which is studied through multiple methods that
conceal the phenomenal awareness of visual stimuli (Brietmeyer). Masking refers to the

idea that when an intense visual stimulus and a less intense stimulus are both presented

within a short interval of time, the less intense stimulus may be masked by the intense

stimulus. The control subject denies seeing the less intense stimulus, but will still respond as

though reacting to both the dim stimulus and the strong stimulus. The weaker stimulus is

masked and is not processed in the subjects consciousness (Taylor and McCloskey). For

example, if a patient is shown a bright light and a dim light within a short interval of time

(about 50 milliseconds in a control patient), the subjects body will react to both of the lights,

but the subject will only report seeing the bright light. Therefore, the dim light is processed in

the subjects unconscious (Taylor and McCloskey). Based off of this research, the subsequent

question is whether or not Parkinsons patients would be able to react to the masked stimuli

since they are processed on the unconscious level in control subjects. The inability of

Parkinsons patients to react to these unconsciously processed stimuli would provide new

insight into the cause of various Parkinsonian symptoms such as drooling and other lapses in

regulation of involuntary movement. Therefore, the standardized course of treatment for

patients in the future should center on these findings to best improve each patients ability to

function despite the wide range of symptoms affecting their unconscious processing

capabilities.

Conversely, some sources may argue that the effects of Parkinsons disease are not

related to the processing of unconscious stimuli, but are limited solely to the various motor

functions impaired by the degeneration of dopamine neurons in the substantia nigra. For

example, they may say that drooling is not caused by a lack of appropriate regulation in the

unconscious processing of swallowing, but is instead caused by bradykinesia (slowness of

movement) in the jaw. This would support the idea that drooling is caused by a motor

symptom, not a lapse in unconscious function. In a 1973 study on salivation in patients with
Parkinsons disease, one conclusion that was drawn was that the excess drooling could be the

result of bradykinesia or abnormal function of the pharynx and esophagus (Bateson et al.).

However, patients with Parkinsons disease rarely report difficulty swallowing (Bateson et

al.). This suggests that the problem is not physical complications with muscles involved in

swallowing; if patients drooled because they were unable to move their mouths efficiently

enough to swallow, or had trouble controlling their esophageal muscles, they would be aware

of this issue. The fact that many Parkinsons patients report drooling but that few report

physical difficulty in swallowing implies that this theory is not accurate or applicable to the

majority of patients suffering from Parkinsons disease. However, the idea that drooling is

caused by a deterioration in ability to process unconscious stimuli is more plausible; this

would account for patients trouble swallowing without any perception of physical difficulty;

they remain unaware of the problem because of its unconscious nature.

These many facets of Parkinsons disease suggest that Parkinsons patients exhibit

progressive deterioration in appropriate response to unconscious stimuli. The progressive

nature of this neurodegenerative movement disorder implies that this complication would

also continue to worsen as the disease advances. Many symptoms of Parkinsons disease such

as drooling, caused by a reduced ability to regulate swallowing in response to the buildup of

saliva, indicate that Parkinsons patients have trouble performing regular actions naturally.

This inability to unconsciously manage various bodily functions is evidence that patients

experience deterioration in unconscious function as a result of Parkinsons disease.

Accordingly, they may also be unable to process and respond appropriately to sensory stimuli

that are processed on the unconscious level in control patients, a phenomenon that can be

investigated through the use of visual masking. Further research is imperative on this topic

because understanding the underlying cause of the extremely wide range of symptoms is

necessary to improve treatment. In the words of Helen Mirren, Parkinson's is a slow but
inevitable process. It's hard living with it on a daily basis. The difficulty facing people with it

is that they never quite know 'Can I or can't I do this today? Parkinsons disease and other

movement disorders have a profound effect on every part of a patients life, from social

interaction to professional aspirations. Those who are not treated properly are unable to

perform simple actions by themselves, and can be confined to a wheelchair. Many symptoms,

including drooling, are embarrassing to patients and their caretakers, and potentially decrease

a patients willingness to leave the house and engage in outside activities. This worsens the

disease by lowering the amount of physical exercise, which has been shown to slow the

progression of the disease. It may also worsen psychological effects such as anxiety and

depression. It is clear that every aspect of a patients symptoms is a key factor in their ability

to cope with their disease, and understanding the causes of each complication is central to

improving treatment.
 Works Cited

Bateson, Malcolm C., et al. "Salivary Symptoms in Parkinson's Disease." Archives of

Neurology, vol. 29, Oct. 1973, pp. 274-75.

Breitmeyer, Bruno G. "Psychophysical 'Blinding' Methods Reveal a Functioning Hierarchy

of Unconscious Visual Processing." Consciousness and Cognition, vol. 35, 2015, pp.

234-50.

Giroux, Monique L. "Disease Progression." Northwest Parkinson's Foundation, NWPF,

nwpf.org/recent-diagnosis/disease-progression/. Accessed 12 Jan. 2017.

Gurevich, E. V., and V. V. Gurevich. "Dopamine Receptors and the Treatment of Parkinson's

Disease." The Receptors: The Dopamine Receptors, 2010, pp. 525-27.

Johnson, Kevin E. "Approach to the Patient with Parkinson's Disease." Primary Care:

Clinics

In Office Practice, vol. 42, no. 2, 2015, pp. 205-15.

Srivanitchapoom, Prachaya, et al. "Drooling in Parkinson's Disease: A Review."

Parkinsonism & Related Disorders, vol. 20, no. 11, Nov. 2014, pp. 1109-18. National

Center for Biotechnology Information, www.ncbi.nlm.nih.gov/pmc/articles/PMC4252747.

Accessed 14 Jan. 2017.

Sveinbjornsdottir, Sigurlaug. "The Clinical Symptoms of Parkinson's Disease." Parkinson's

Disease, edited by John Hardy and Jrg B. Schulz, special issue of Journal of

Neurochemistry, vol. 139, 11 July 2016, pp. 318-24.

Taylor, Janet L., and D. I. McCloskey. "Triggering of Preprogrammed Movements as

Reactions to Masked Stimuli." Journal of Neurophysiology, vol. 63, no. 3, Mar. 1990, pp.

439-46.