Question: Your patient is male and 46 years of age. He has been diagnosed with clinical depression, paranoia, anxiety with episodes of psychotic features. Prior to the onset of his mental health condition, he was of exemplary character with high moral values and principles. 

1) Can an individual suffering clinical depression and psychotic features become more susceptible to being influenced and manipulated by others into doing things which are morally wrong and against the individual's long-standing premorbid high principles and morals ? 

2) Can hallucinations or delusions be so robust that the patient can be compelled to do consequent acts that would seem highly incongruous with the patient's morals, values or typical behaviours? Do you honestly feel that the patient's mental health condition (as referred to above) can be the cause of that atypical behaviour or is it a premorbid personality trait that had been dormant for 46 years ? 

3) Do you honestly feel that the above disorders can provide a  medical explanation (rather than refer to it is a medical excuse) for behaviour which would hitherto be considered highly incongruous with the individual's personality and compel the person to do things contrary to their feelings of right and wrong and despite feelings of guilt and remorse ?  

I should like to thank you in anticipation of your answers to the above.

For nearly 20 years I was in charge of a real estate office dealing with the sale of residential property. I was often described by my peers as the consummate professional; known for my honesty integrity and fairness. I won Professional Awards at regional and national level.

Briefly I have suffered from depression since 2008, if not earlier.

In 2010 somebody in my workplace found out about an embarrassing congenital problem which my wife had experienced. I was subjected to anonymous emails which were malevolent and became threatening and blackmail in nature. I reported it to my XXXXXXX business partner who said I should report it to the police. However, I thought the repercussions would be too severe and would affect innocent people like the culprit's family (I initially suspected an employee who was the son of my best friend) and also the embarrassment of my wife's problem would have been public knowledge and cause ridicule and embarrassment for her, myself and my sons.

Therefore I tried to appease my tormentor by ascertaining what the issues were and I even tried to meet what appeared to be demanded of me. Its complicated, but I even offered the owner of a similar business a figure of £18,000 to offer one of my employees a job in order to appease the blackmailer, but I was incorrect.

Anyway, I became more paranoid and very depressed. I went on a sabbatical in 2012 and had a few therapy sessions with a psychiatrist and a psychologist. I was given anti-depressants which gave me awful side effects. I experienced hallucinations and heard voices. I mentioned them to two friends who both cautioned me by suggesting that if I told my psychiatrist that I would be diagnosed with schizophrenia or bipolar and then not permitted to return to my business and therefore be unemployed. Their advice was wrong, as I found out earlier this year, having been informed by another psychiatrist that my psychotic features were as a result of clinical depression and not schizophrenia or bipolar disorder.

In XXXXXXX 2012 I was feeling terrible. Another junior colleague started spreading inaccurate rumours that I had a mental breakdown, would not be returning to the firm and he was taking over my job. I reacted by sending my XXXXXXX partner an email to which he replied. I misinterpreted his reply and I sent a hastily written, ill-considered response which I later realised was so easy for any reader to misinterpret. That email lost me the support and goodwill of my business partners.

I became suicidal. I had hallucinations. I decided that I must get access to the emails on my office computer and retrieve the emails and have them traced to the culprit and then my partners would see with their own eyes what I had been subjected to. However the XXXXXXX partner would not allow me near the office ; I thought perhaps it was because he feared that the culprit might be another key member of the firm. I was distraught and suicidal. I emailed the Samaritans and also sent messages to an on-line friend (GS) who has bipolar disorder, is a leader of a support group / forum and has studied mental health disorders. GS kept emphasising to me that the only way to ensure my return to the business of which I was a partner, was to use deception to gain access to my former office, then access my computer and the emails I received, have them traced and discover the identity of the blackmailer. I kept telling GS that I could not do it because it was immoral. But GS insisted that I had been the victim of immoral acts (threats and blackmail) and that the only way in which to achieve an equitable ending would be to lie to two of my business partners. I relented and sent an email to The Samaritans telling them what I was going to do and stated that once I knew who the blackmailer was then I would admit to my deception. For the first time in 20 years I lied to two of my partners. My deception failed and I ended up being branded the wrongdoer rather than whoever it was had tormented my for over 2 years. .

This was totally out of character. I had always been honest in everything I did ; personal and professional, but I had lost touch with reality and was fearful of colleagues and questioned motives of even those business partners who, in reality, were trying to help me recover to full-health and return to work. The frequency of hallucinations increased and I was so confused. Despite my reactions being to always do what is right and correct my judgement in going ahead with what GS had suggested was totally lacking rational thought. Regrettably I left the firm after 20 years. I have been suffering depression, remorse, guilt, trauma ever since.

Ever since 2012 I have tried to persuade my former partners to allow access to my old PC and prove who the source of my problems was. But they seem disinterested. GS kept telling me it was perhaps because they cannot afford to have the culprit identified if it is an employee in a key role.

I am in continual torment ; partly because I cannot understand what went wrong with me – despite the psychiatrist saying that I had clinical depression, paranoia and anxiety disorder, plus the delusions and hallucinations. I question how I allowed the illness take control, affect my thoughts and reactions ; for me to react in totally uncharacteristic ways. Also the torment of not being able to achieve closure by knowing for sure who it was who persecuted me for nearly two years.

I have suffered insomnia for probably 6 or 7 years. I can get to sleep at night but then wake between 3.30 and 4.30am. In recent years it has been soon after waking that I get panic attacks, anxiety and sometimes auditory hallucinations. Since summer 2014 it has resulted in me often waking in the middle of the night, get anxiety attacks, sometimes hearing a voice and then reacting by sending texts or emails to my former partners asking them to try to understand what happened and asking them to help me – even sending messages at that time of morning. I know it is wrong to do so but I felt compelled to do so and sometimes the voice directs me to do so. Once I sent the text / email I felt a sense of relief but also guilt and remorse for having done so. Despite that, perhaps a day or two later I will find myself waking at 4am and compelled to text them again.

There are many times when I look back and cannot recognise the person I appeared to be since 2010 and particularly from 2012 onwards. My behaviour, reactions etc were highly incongruous with my normal behaviour and high principles and values. I ask myself the question "was it the illness that causes me to act wrongfully and out of character ?"

In hindsight I find it difficult to recognise the person I have been at times since 2010-11. People who have known me for more than 30 years cannot understand why I have acted / reacted as I have done.

In spring 2014 my on-line friend GS said the only way forward was to explain to my former XXXXXXX partner (“H”) about the symptoms of my illness and its effect upon me and the consequent uncharacteristic behaviour.

He volunteered to email H and explain it to him. GS also considered that he would then be able to persuade “H” to allow access for an IT firm to retrieve the original anonymous emails that I receved in 2010 - 11 and trace them to the sender. This was something that “H” had not been prepared to do after I left the company because he said he did not want to rake up the past.

GS sent an email to “H” to which came a reply of :- noted, thanks. I said to GS that “H” tended to be short / brief in his emails. GS let matters rest. However, I was getting more severely depressed and suffering auditory hallucinations in July / August 2014. GS was aware of this and, unknown to me, decided to email “H” again but this time pretending to be a doctor. GS used his knowledge and experience of Bipolar to explain depression and also psychosis to “H” and its effect upon me. This time “H” sent a longer response and expressed appreciation of what he was being told.

GS apparently continued and asked “H” if the firm would consider me returning one day. “H” sent a response that after a period of at least two years, during which I am seen to have recovered to as near normal health as possible, that the firm would consider my return. GS then forwarded “H”s email to me. Although I was pleased to read H’s comments, I was alarmed to see that GS had used an alias and worse still, used the title Doctor. I expressed my disapproval to GS. He responded by saying that it was the only way that he could get “H” to take notice of what was being written. I told him to stop but GS continued contacting “H” and later told me that he did so in order to try to gain H's trust and get him to agree to having the threatening emails located and traced to the source.

GS, who is definitely bipolar and I have since been told is possibly schizophrenic, got very frustrated and I understand his emails to “H” became more forceful in nature. When I discovered what GS was doing I told him he must stop, but he did not listen.

I woke one morning at 3am and was in a terrible state. I heard a voice telling me to " contact “H” and stop GS" . The voice repeated it a few times during the next hour. I knew that GS would not listen to me, but then thought that just as “H” was more prepared to listen to a doctor than to lay people, I decided to send GS an email from a fictitious Dr T. Despite my feelings of guilt and knowing the rights and wrongs, I then entered into emails with GS in order to stop him. I then discovered that he was causing “H” annoyance. I became very anxious and started hearing the voice again when I woke. So, in order to calm things down, I sent “H” an email as Dr T and apologise for GS’s unprofessional behaviour. “H” replied and was very grateful. “H” also added that GS had tried to coerce him into defrauding his partners and allow the source of the 2010 emails to be traced.

I was appalled when I read what GS had done. I sent him emails as myself and as Dr T telling him that he must stop. “H” sent an email to Dr T saying that he felt like reporting GS to the police but that he was probably in need of medical help himself.

I then heard from another Forum user that GS had appeared in Court for wrongful behaviour while manic. He got a community supervision sentence of one year. I realised that GS was dangerous, uncontrollable, volatile.

I felt terrible guilt in having taken a leaf out of Geoff's book by creating a ficticious doctor in order to stop him.

I felt even worse in deceiving my former business partner “H” by using the identity of Dr T in order to calm matters down between him and GS. I felt such guilt and remorse that it made me feel even worse ; sleepless nights and more panic attacks, more damn voices.

I then discovered that GS had become obsessed with his aim to get “H” to allow access to the PC on which the 2010 emails were stored and that he had created yet another identity and emailed HJ - this time as a private investigator. HJ replied by saying that he was going to China for 2 weeks and would get his IT technicIans to locate and trace the emails upon his return.

Although I was again appalled at Geoff's deception, there was some relief in that upon reading the email from HJ about retrieving the emails it felt as though the torment that I had endured since 2010 would soon be over ; the emailer would be caught. I reacted by sending an email from Dr XXXXXXX to HJ saying that DrC had mentioned that HJ was going to allow access to the PC upon his return from China in early December. HJ was very amienable in his response.

In hindsight, I cannot believe that I created a false identity and deceived “H” and GS while trying to calm matters down but then later, upon learning that “H” had finally agreed to "raking up the past" , sending “H” a further email. It was heinous. Despite the voices I was hearing and the utter confusion in my head I should not have done so. It was meant just to calm things down between GS and “H” but it got out of hand. My illness is no excuse - I feel great remorse and guilt for doing so.

The guilt became too much. I felt that I had to contact my other former partner “J”. I had texted him several times when waking in the early hours of the night. I could not sleep for 2 nights. One morning in late November I somehow found myself in the car park near “J”s office. I could not recall the journey there nor my decision or purpose in doing so. “J” arrived so I walked over to him. I was very emotional and apologised for all the concern that I had caused. I mentioned about “H” agreeing to retrieve the emails. “J” seemed surprised and said that he would have to speak with “H” upon his return. I realised then that he would not allow it to happen. I broke down. I said sorry and returned to my car.

When “H” arrived back from China I heard nothing about the emails being traced. All my hopes were lost. However the guilt and regret and remorse for deceiving “H” with my Dr T emails did not end there – the feelings of guilt and remorse continue.

At the recommendation of my former business partner, “H”, since early March I have seen a psychiatrist. He diagnosed clinical depression and we have talked about the anxiety attacks and psychotic features. I am on medication and I am recovering.
I appreciate that what I have written takes a lot of effort to absorb and take-on-board. My current psychiatrist wants to deal with the present and provide medication to treat the depression etc. I have a psychologist, but he also seems to wish to deal with the “here and now” and look ahead rather than go over what happened during 2010 – 2014.

I know that had I been well in 2010 that I would have acted rationally. The same for my actions / reactions sInce then.

The problem is that most people do not want to know anything about mental health issues - they disengage, there is a stigma. There have been many times when I have wished I had cancer instead of mental health disorders because then people would sympathise, they would try to understand.

NOW MY FOLLOW-UP QUESTION :-

Having read the above, do you still think that it is possible my mental health disorder ( the combination of depression, psychotic features, anxiety attacks in the night which caused lack of self control) has caused the wrongful problematic behaviour which people who know me find highly incongruous with my typical values and high principles.

Or is it more likely to be a premorbid, dormant personality trait which has caused my problematic behaviour ?

I should like to thank you in anticipation of your assistance.

Thank you for your response, which is very similar to that of other psychiatrists and psycholigists i.e that it is the illness that has caused problematic behaviour which, when compared to the person before the outset of the illness, would be considered highly incongruous with the person's high values, morals and principles.

Despite the mental health professionals arriving at the same conclusion - that the problematic inappropriate behaviour is caused by the illness and not a personality trait, why is it that the public in general find it so difficult to accept that mental health disorders eg pyromania, kleptomania etc can compel people to behave in ways which may conflict with their morals and decent principles ?

Is there any example of the effect of a mental health disorder which would be easier for people to accept eg I would assume it can be said of a Kleptomaniac or perhaps a Pyromaniac that even if the person, before the onset of illness was of good character and knew right from wrong, he is compelled by the illness to commit the wrongful act, and despite feelings of guilt and remorse afterwards, the condition forces him to repeat the wrongful act. Is my understanding correct ? Would you have a better example or explanation to give to lay people ?

For example, when you were a student of medicine there may have been students who doubted that illnesses can take control of a person's behaviour and he can perhaps act without volition. How did your tutor explain in order to convince students that this is the case ?

Thank you for your reply. You have said that I am free to ask further, so I hope you do not mind my doing so.

During 2011-2014 I sent numerous emails and facebook messages to two other parties ; one a friend of many years (AW) and the other an on-line friend (GS) of whom I have referred before.

The contemporaneous records refer to how I was feeling at the time, my anxiety, my confusion. I suppose it creates an anamnesis.

When I look through the emails and messages I find it hard to recognise myself as the author - I appreciate it is easy to say anything in hindsight but I simply find that to be the case. I obviously did send them because the records show that I did so, but I do not recall doing so. Indeed, I sent messages to GS at the time saying that I could not recall having done so.

There are times during 2012 and 2014 that I have difficulty recalling e.g.

a) during July and August 2012 when I was going through the process of leaving my business, I went abroad on holiday with my family. I cannot recall having done so. My family say that during the holiday I was not focused, it was as though I was in a different world and was cumbersome and confused during conversations.

b) in Sept 2014 I met my former business partner (H) for a coffee and chat. He mentioned to me that I must stop sending texts to my other former business partner (J) during the middle of the night. I could not recall having done so.

My messages to GS and AW in summer/autumn 2012 and summer/winter 2014 refer to hearing voices so I suppose they are times when the psychotic features prevailed.

Q1 ) Is the partial loss of memory of events such as those mentioned in (a) and (b) have any significance ? Is it a case of being overwhelmed by the hallucinations and delusions at the time that it leads to some loss of memory ?


I have seen in the messages to and from GS that during 2012 and 2014 he repeatedly tells me the only way to achieve justice is to force my former business partners to allow access to me old computer, retrieve the malevolent emails I received and trace the sender. GS says that it is the only way in which I can return to my former firm.

GS suggests throughout various means including deception of my former business partners and suggests that upon identifying the original culprit I can then admit to my business partners my deceit which as GS puts it is "a means to an end" and that I "must fight fire with fire" and "an eye for an eye, tooth for a tooth". There is evidence of me disagreeing with GS's suggestions, that an immoral means to achieve a moral or equitable end is not justifiable, it is wrongful. There are times when I tell him that it is against my principles and morals to act as he suggests.

Notwithstanding the above, evidence shows that I have done as GS suggests. I have used deception to mislead my former business partners to enable access to my old computer and trace the person who sent me the malicious emails in 2010-11. The problem is that I only have some recollection of having done so.

I find it hard to believe that despite feeling guilt and remorse after the event (eg the reports of me sending texts) that something in my head told me to do so again.

In hindsight I find it all heinous, loathsome. That I should do things that are against my principles and moral values.

Q2) Could it be the delusions and hallucinations that overwhelmed my normal senses of rights and wrongs, long held good principles and to have given in to the suggestions of GS (who I have since learnt bad things about) ?

I should like to thank you in anticipation of your reply.

Following our discussion about the background of my illness and the stressors, environmental and interpersonal issues, last evening I asked my psychologist Prof XXXXXXX Frude if my wrongful behaviour which is incompatible with my premorbid behaviour, is due to the illness etc OR a dormant personality trait ? He insisted that it was a reaction to the illness and not a personality trait or disorder.

I had prepared a long, chronological account of tbe past events but somehow it did not get saved on the healthcare system.

However, as a result of last evenings discussion with Prof Frude, it appears that he, your goodself, Dr Kausak - psychiatrist, and Dr XXXXXXX - psychologist, are all of the same opinion - the atypical behaviour is because of the illness and not my personality / a hitherto dormant personality trait.

If I am to have any opportunity to return to my old firm, then it will be beneficial to have a psychistrist assess me and hopefully arrive at the same conclusion and prepare a report. Do you think a forensic psychiatrist is the best type of psychiatrist to deal with such a matter ?

Your continued advice and any further recommendations is appreciated.

Kind regards XXXXXXX

Dear Doctor

Thank you for your reply. You mention that you will be happy to help me in the future, which is very much appreciated. Are you, or could you be placed in a position wheteby you can provide a report through your practice? I understand thst here in UK thete are some psychiatrists using video links to interview clients.

Hello Dr Mehta

In your experience :-

1) is it usual that during psychotic episodes the patient has no loss of memory of his / her past or can there be temporary loss during psychotic episodes ?

2) is it usual that actions or behaviour carried out during psychotic episodes can be forgotten once the patient has returned to a "normal state" ?

3) is it possible that a patient suffering clinical depression with irregular sleeping patterns can wake in the night, ecperience anxiety attacks and then experience hallucinations which are not caused by psychosis ? If so, can those hallucinations be as compelling as those associated with psychosis ?

4) in my experience the hallucinations and delusions were like being taken to some wild far off land, a bewildering place to which I would visit and return fromsometi es in the space of an hour or two. Is that unusual ?

5) can it be said of psychosis that it is not a total or permanent state of mind; that one can drift in and out of it and even operate / function at the highest of levels ?

Thank you.

Hello Doctor

I am sorry. I have just realised that I have already asked you questions 1 and 2 but in a slightly different wording. So perhaps you may feel it unnecessary to reply to those two.

However, can you please answer this additional question :- you have previously said that individuals with psychotic episodes and depresdion can often be manipulated by others. Is it quite possible that another person with immoral intent can speak to the patient and plant thoughts in tne patient's mind which then

However, can you please answer this additional question :- you have previously said that individuals with psychotic episodes and depresdion can often be manipulated by others. Is it quite possible that another person with immoral intent can speak to the patient and plant thoughts in the patient's mind which then can influence the thoughts and reactions of the patient during a psychotic episode, that is affect the patient's hallucinations and delusions.

For example if the patient (P) who shall we say is a principled and moralistic person in a premorbid state, was falsely told by a vindictive person that a third party (T) was a bad person who was trying to cause harm, perhaps to (P) himself, is it then possible that although (P) may not believe what he has been told by the bindictive person about (T) to be true or at least has doubts as to the accuracy of the accusation, that during the psychosis the hallicinations and delusions an be influence by the accusations about (T) and result in (P) reacting uncharacteristically in a harmful way towards (T) ?

Thank you.

Dear Doctor

Is it possible for a person suffering psychotic features with hallucinations and delusions to be influenced in this way :-

The patient is somebody of exemplary character and complies with societal moral values and principles.

During psychotic periods another person XXXXXXX who has immoral and vindictive motives repeatedly tells the patient that his friend XXXXXXX is evil and trying to cause harm to the patient and that he must retaliate in order to protect himself. The patient protests and does not wish to cause harm to his friend.

However XXXXXXX repeatedly tells the patient that XXXXXXX is harming him.

Is it possible for XXXXXXX to influence the patient in such a way that he then becomes deluded to the extent that he becomes convinced that his friend XXXXXXX is indeed causing him great harm and that he must retaliate in order to protect himself and prevent further harm ?

Therefore can a person's delusions be influenced by a third party providing misinformation to the psychotic person ?