Case reports:

Patient 1 is a 70-year-old woman, who had been treated with weekly intramuscular injections of fluspirilene, a diphenylbutylpiperidinic depot neuroleptic with a tranquillizing action for an anxiety disorder. She received no other neuroleptic agents. Six to twelve months after cessation of the neuroleptic treatment involuntary movements progressively developed, comprising of oro-buccal-lingual dyskinesia, blepharospasm, painful phasic opisthotonic posturing of the neck and retropulsive twisting movements of both arms. There was no involvement of the legs and only minimal involvement of the trunk. The remaining neurological status was normal. Subsequently, extensive pharmacological treatment trials including baclofen, botulinum toxin, bromocriptine, clonazepam, clozapine, diltiazem, DL-alpha- tocopherolacetat, gabapentin, pimozide, tetrabenazine, tiapride, trihexyphenidyl, and verapamil had no lasting effect on the movement disorder over a period of six years. Preoperatively, she was still on lorazepam (4 mg/d) for her anxiety disorder.

Patient 2 is a 66-year-old woman, who was started on weekly intramuscular injections of fluspirilene for a single episode of a psychotic depression in 1997. Three months later she noticed an involuntary extension of her right arm and an elevation of the shoulder as well as a progressive twisting retroflection of her neck. There was no obvious facial involvement. Her remaining neurological status was normal. No change in motor symptoms was observed after withdrawal of fluspirilene. Subsequently, treatment trials including budipine, clozapine, sulpiride, and tetrabenazine did not result in a beneficial effect. There was no need for a psychotropic therapy the last three years before DBS.

Patient 3 is a 56-year-old woman, who received haloperidol intermittently over 30- years for a bipolar depression. 1992 she noted involuntary movements of her mouth and tongue, followed by a twisting of her right arm and painful phasic retroflections of her neck three months later. No other abnormalities have been detected. Besides the withdrawal of haloperidol she received numerous treatments for her painful dyskinesias comprising botulinum toxin, clozapine, lorazepam, tetrabenazine, tiapride, trihexyphenidyl and spinal cord stimulation which all did not translate into a lasting benefit. The last couple of years she did not take any psychotropic medication.

Patient 4 is a 30-year-old man, who was treated intermittently with benperidol, levomepromazine, and haloperidol for a paranoid schizophrenia with religious delusions starting in 1994. Four years later he complained of unintentional movements of his left foot. The following months he noticed a spreading of involuntary movements to his left arm and his face. On examination he showed evidence of akathisia including pacing and constant fidgeting movements of the hands and feet. He showed mild orofacial and limb dyskinesia, including piano- playing choreic movements and quick jerking bending movements especially of his left arm. His gait was characterized by arching extension of the back and neck as well as dystonic foot posturing. There was no family history of dystonia. Treatment trials including the withdrawal of neuroleptics as well as amantadine, clozapine, DL- alpha-tocopherolacetat, olanzapine, tetrabenazine, and tiapride and had no lasting effect. Preoperatively the patient was on lorazepam only for treating the violent dyskinesias. He presented with a normal psychiatric status and had been without psychotic symptoms for the past two years despite the discontinuation of neuroleptic treatment.

Patient 5 is a 59-year-old man, who developed a severe tardive cervical dystonia (CD) following three years of treatment with haloperidol for a major depression with paranoid delusions. After onset of CD, haloperidol was discontinued. The patient remained stable on low-dose benzodiazepines (lorazepam 4mg/d) and did not have psychotic episodes for at least four years. Preoperatively, a mild depression was present.