In Reply.—Drs Orr and Golden have commented that, in my editorial concerning their article on SIA, I misinterpreted their message. In carefully reviewing their article and my editorial, perhaps I have. The authors define SIA as surreptitious insulin administration in patients with IDDM who "have preexisting psychological problems, in our experience." The authors comment that all patients had been identified as having psychosocial problems and evaluation before the onset of SIA. However, it is not clear from the two cases presented in detail what these evaluations showed and if they were different from the evaluations after the discovery of SIA. Thus, Thus, was not clear that psychopathology predated the appearance of SIA.
I did suggest that SIA may result after responsibility for the patient's disease had been taken from them. In fact, the authors state that "previous transfer of responsibility from the patient had eliminated the ketoacidosis." Furthermore, they