Homeless people in inner Sydney have death rates three to four times higher than people in the general population of New South Wales. Excess mortality was greatest for younger age groups.

The purpose of the present paper was to describe the circumstances and phenomenology of patients who remove or pierce their eyes or orbits during psychotic illness. In particular, the aim was to determine if patients in their first-episode psychosis (FEP) carry an increased risk of self-inflicted eye injury when compared to patients with previously treated psychosis (PTP). Data were extracted from all of the case reports published in English since 1960 and from two unpublished Australian cases. More than half of the cases of self-inflicted eye injury that resulted in permanent loss of vision occurred during FEP. Serious self-inflicted eye injuries are rare, but the risk appears to be greatest during FEP. Earlier treatment of emerging psychosis and close attention to patients who attempt to injure their eyes may occasionally prevent blindness.

Intracranial self-stabbing appears to be an under-recognized form of self-harm that is associated with, but not limited to, psychotic illness.

The possession of severe mental illness, mainly schizophrenia and affective psychosis, may be perceived in positive terms. We have identified a group of patients, most of them with a history of previous psychotic disorder, who present with deliberately created symptoms and behaviour, and who are defined as having instrumental psychosis. Because most such patients have had a psychotic disorder in the past the symptoms are very like those of a real psychosis. A parallel is drawn with the fictional anti-hero of the Czech nation, the Good Soldier Svejk, who demonstrated both real and instrumental psychosis. A rating scale, the 'pseudopsychosis inventory', was devised to identify the main components of this disorder and was applied in 15 consecutive patients presenting with putative psychotic disorders in whom assessment could be made by two raters within five days. The inter-rater reliability of the items of the scale was good (intra-class correlation coefficient 0.68). An epidemiological study with this scale in 45 patients with a putative psychotic disorder suggested the presence of instrumental psychosis in 2.

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