This case illustrates the complexity of certain diagnostic situations and the invaluable part that a neuropsychological evaluation plays in making accurate diagnoses. We present the case of TL, a 52-year-old male with 12 years of education and a 20+-year history of alcohol abuse, who was found wandering in the snow in a seeming delirium. His frost bite was so severe that surgeons decided on bilateral leg amputations. On a psychiatric consultation to assess his competence prior to giving consent for the surgery, he was found to have Korsakoff's syndrome. Although his clinical presentation included both anterograde and retrograde memory deficits, the most significant features of his presentation were his many, dramatic, and fantastic confabulations. Although clinically, the diagnostic impression of Korsakoff's seemed to fit, extensive neuropsychological and personality testing after surgery failed to reveal the presence of an amnestic syndrome; nor did he manifest the hallmark radiographic features of the Wernicke-Korsakoff syndrome, but rather generalized atrophy. A diagnosis of alcoholic dementia with residual schizophrenia was made, as he demonstrated a significant thought disorder on psychological testing. Although structured neuropsychological testing was insensitive to his psychiatric status, neuropsychological test scores (IQ vs. Memory) and the ability to differentiate confabulatory responses from delusional thought processes were crucial in making the correct diagnosis.
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