Background <p>Schizophrenia, a debilitating psychiatric disorder affecting ~1% of the global population, is characterized by positive, negative, cognitive, and neurological symptoms. Motor abnormalities are an under-recognized component and, if overlooked, may result in permanent deformities. Clenched fist syndrome is a rare clinical entity, with etiologies ranging from congenital and traumatic causes to psychiatric disorders, often in the absence of identifiable organic pathology.</p> Case presentation <p>We report the case of a 24-year-old South Asian male from Karachi, Pakistan, diagnosed with schizophrenia, who presented with bilateral persistent clenched fists for 6 years, which significantly worsened following the death of his mother. Comprehensive physical, neurological, and radiological evaluations revealed no underlying organic cause, supporting a psychogenic etiology. Despite multidisciplinary treatment, including antipsychotic therapy, physiotherapy, casting, and electroconvulsive therapy, no improvement in hand posture was achieved, likely owing to the prolonged delay in diagnosis and intervention.</p> Conclusion <p>This case highlights the importance of early recognition and timely management of motor manifestations such as clenched fist syndrome in psychiatric disorders, which are frequently overshadowed by prominent psychotic symptoms. Delayed diagnosis may lead to irreversible musculoskeletal changes, emphasizing the need for clinician awareness and further research into the pathophysiology and optimal management of clenched fist syndrome.</p>