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A 48-year-old man diagnosed with paranoid schizophrenia presented to our department complaining of neck discomfort and involuntary movements in the orofacial region. He reported that his first complaint was difficulty in his relationship with his wife when he was 28 years old and then hearing voices was added. Since his complaints increased into the next 2 years he was taken into a psychiatric hospital and diagnosed with paranoid schizophrenia. He had used one 200-mg zuclopenthixol depot injection per month, and biperiden 6 mg and sulpride 100 mg daily for 1 year. At the end of the 8-month treatment with these drugs, he presented with involuntary movements of the orofacial region, with difficulty swallowing and chewing. At the same time, he developed involuntary sustained contraction of the neck muscles. These involuntary movements exacerbated over the next months until his speech became dysarthric and his neck became severely disabled. Five months after the initiation of his symptoms he began smoking cannabis 3 or 4 times a week for 2 years and observed that his involuntary movements significantly decreased. For this reason, he continued smoking cannabis to self-treat his symptoms until he was arrested due to smuggling. He stopped smoking cannabis and his symptoms then exacerbated and became fixed during the 7 months he was in prison. The administration of the same antipsychotic drugs was continued in prison.
On admission to our clinic the general physical examination was normal. Neurological examination showed an alert patient with dysarthric speech. His head was turned to the left and upwards due to the sustained contraction of his neck muscles. There were continuous oro-buccolinguo- masticatory dyskinesias as well. The neurological examination was normal, except for fixed dystonic posturing in the neck muscles and orofacial dyskinesia. Family history of movement disorders and psychiatric disease was negative. Cranial and cervical magnetic resonance imaging, electroencephalogram, full blood count, serum chemistry, thyroid tests, serum ceruloplasmin...