For many years, regulation enforcement officers, medical experts and emergency medical professionals have used the phrases “excited delirium” and “excited delirium syndrome” to explain topics experiencing excessive agitation, excitability, paranoia and aggression, typically related to stimulant use and sure psychiatric problems. Whereas officers proceed to come across topics displaying such signs, the time period “excited delirium” has come beneath important scrutiny and is now disavowed by main medical and psychological organizations, together with:
- The American Medical Affiliation
- The American Psychiatric Affiliation
- The American Academy of Emergency Drugs
- The Nationwide Affiliation of Medical Examiners
- The American Faculty of Medical Toxicology
- The American Faculty of Emergency Physicians
Lexipol eliminated the time period “excited delirium” from our coverage steerage in 2022. No matter your company’s coverage on the usage of this time period, it’s useful for regulation enforcement officers to know why the medical group has advanced away from utilizing it.
Outdated understanding
For nicely over a century, medical specialists have used numerous phrases to explain a situation wherein topics expertise:
- A disturbed way of thinking, together with anger, violent habits, concern and panic
- Elevated physique temperature (hyperthermia), normally coupled with extreme sweating
- A sudden pause within the habits, throughout which topics cease struggling
- Sudden respiratory arrest, typically resulting in dying
This situation has variously been labeled “Bell’s mania,” “acute exhaustive mania,” “deadly catatonia” and “agitated delirium.” In 1985, on the top of the U.S. crack cocaine epidemic, researchers Charles Wetli and David Fishbain dubbed the situation “excited delirium,” noting it typically co-occurred with cocaine use (although sometimes at drug concentrations decrease than seen in circumstances of cocaine overdose). The time period was typically shortened to “EXD” (for “excited delirium”) or “ExDs” (for “excited delirium syndrome”).
A report on the subject within the Western Journal of Emergency Drugs famous that “excited delirium” and “agitated delirium” described a topic exhibiting “agitation, aggression, acute misery and sudden dying, typically within the pre-hospital care setting.” The report identified that about “two thirds of EXD victims die on the scene or throughout transport by paramedics or police.” Citing Wetli, the report famous those that died with out contact with the police have been typically found in a rest room after obvious makes an attempt to chill their physique temperature utilizing moist towels and ice trays.
An article in Pressure Science said the signs labeled as “excited delirium” might be attributable to various very completely different medical situations:
- Hyperthermia: An individual with an inner physique temperature of 102 or greater could exhibit signs just like alcohol or drug intoxication.
- Diabetes: A diabetic individual with low blood sugar could exhibit sudden modifications of temper, confusion and bursts of anger – plus an elevated coronary heart charge, extreme sweating and even seizures.
- Head damage: Somebody with traumatic mind injury could don’t have any seen accidents however nonetheless present indicators of mania, disorientation, psychosis and different aggressive conduct. As well as, these signs could manifest months and even years after the top damage occurred.
- Delirium tremens: Somebody with “the DTs,” or alcohol withdrawal, can manifest signs just like these related to “excited delirium,” together with temper swings, nervousness, physique tremors, extreme sweating, paranoid ideas and hallucinations.
- Thyroid storm: Extra frequent in girls than males, the uncommon situation of thyroid storm can look similar to “excited delirium” in a topic.
Throughout the 2000s and 2010s, officers could have been taught to acknowledge and reply to “excited delirium” as a part of academy and post-academy coaching. Through the years, steerage has modified. Early techniques typically various dramatically from company to company. As understanding of the dangers of sure restraint positions grew to become extra widespread, steerage advanced to favor avoiding a chronic wrestle every time attainable. When a relaxed and deliberate strategy proves ineffective, then the usage of different restraints and management strategies (versus ache compliance measures) is most popular.
Maybe an important steerage over the previous decade or so has been the necessity for officers to acknowledge these topics as experiencing a medical emergency, and name EMS as shortly as attainable.
Problematic utility
In accordance with a 2022 report ready by Physicians for Human Rights (PHR), a number of research have instructed that diagnoses of “excited delirium” could have been used to justify extreme use of pressure by regulation enforcement. A glance into in-custody deaths in Auckland from 2005 by means of 2017 confirmed that “excited delirium” was blamed for 17% of the 289 circumstances. A related research in Auckland demonstrated the identical sample: 85 deaths blamed on the situation over a interval of 10 years.
After an intensive assessment of the literature and session with specialists, the PHR report additionally concluded that “the time period ‘excited delirium’ can’t be disentangled from its racist and unscientific origins.” For instance, a 2021 article within the Virginia Legislation Evaluation revealed that, of 166 in-custody deaths throughout the nation, Black topics made up over 43% of these with “excited delirium” listed as a attainable reason for dying. That proportion rose to 56% when Black and Hispanic topics have been mixed.
The turning level
It was after the 2020 dying of George Floyd when many People could have first heard the time period “excited delirium.” Within the viral video that shocked the world, one of many responding officers talked about the situation whereas one other officer had Floyd in a inclined place on the bottom. That officer was later convicted of unintentional second-degree homicide, third-degree homicide and second-degree manslaughter. The officer who had talked about the situation of “excited delirium” later pled responsible to aiding and abetting second-degree manslaughter.
APA Place Assertion on “Excited Delirium”
Within the wake of Floyd’s dying and the following demonstrations and unrest, many organizations – together with the American Psychiatric Affiliation (APA) – revisited their positioning on the usage of “excited delirium” in police experiences, coroner’s experiences and information tales. In December 2020, the APA made the next official assertion on the usage of the time period:
It’s the place of the American Psychiatric Affiliation that acute medical situations, together with Delirium, at all times require an acceptable medical response. Subsequently, it’s the place of the APA that:
1. The time period “excited delirium” (ExDs) is simply too non-specific to meaningfully describe and convey details about an individual. “Excited delirium” shouldn’t be used till a transparent set of diagnostic standards are validated.
2. An investigation ought to be undertaken of circumstances labelled with “excited delirium” to determine how the time period is getting used, whether or not constant standards are being utilized, and whether or not it has any validity as a medical syndrome. The U.S. Division of Well being and Human Companies ought to conduct a complete, nationwide investigation of cases wherein people have been recognized as being in a state of excited delirium, together with in interactions with regulation enforcement personnel and different out-of-hospital contexts. The research ought to embrace examination of all related knowledge, together with the precipitating occasions, well being outcomes for the people and regulation enforcement personnel, and whether or not there’s a disproportionate utility of the time period “excited delirium” to individuals with psychological sickness, Black folks, or different racial and ethnic teams.
3. All jurisdictions ought to develop, implement, and routinely replace evidence-based protocols for the administration of ketamine and different sedating drugs in emergency medical contexts exterior the hospital. These protocols ought to enable use of those drugs just for therapy functions in medically acceptable conditions and may explicitly bar their use to realize incapacitation solely for regulation enforcement functions.
The APA identified that the DSM-5, essentially the most present replace to the Diagnostic and Statistical Guide of Psychological Issues, doesn’t record “excited delirium” as an precise psychological situation. It additionally factors out that EMTs routinely handled topics suspected of getting EXD with ketamine, which has the potential to trigger respiratory arrest. Due to this, the APA says, “it’s questionable whether or not the individual recognized as having an ‘excited delirium’ truly had any medical situation warranting its use.”
AMA Place Assertion on “Excited Delirium”
Half a yr later, in June 2021, the American Medical Affiliation (AMA) put out its personal press launch stating the group’s place concerning the time period:
A coverage adopted by physicians, residents, and medical college students on the American Medical Affiliation’s (AMA) Particular Assembly of its Home of Delegates (HOD) opposes “excited delirium” as a medical prognosis and warns in opposition to the usage of sure pharmacological interventions solely for a regulation enforcement function and not using a reliable medical purpose.
The brand new coverage addresses experiences that present a sample of utilizing the time period “excited delirium” and pharmacological interventions reminiscent of ketamine as justification for extreme police pressure, disproportionately cited in circumstances the place Black males die in regulation enforcement custody. Particularly, the coverage:
- Confirms the AMA’s stance that present proof doesn’t help “excited delirium” as an official prognosis, and opposes its use till a transparent set of diagnostic standards has been established
- Denounces “excited delirium” as a sole justification for regulation enforcement use of extreme pressure
- Underscores the significance of emergency physician-led oversight of medical emergencies within the area
- Opposes the usage of sedative/hypnotic and dissociative drugs – together with ketamine – as an intervention for an agitated particular person in a regulation enforcement setting, and not using a reliable medical purpose
- Acknowledges the danger that sedative/hypnotic and dissociative drugs have in relation to a person’s age, underlying medical situations, and potential drug interactions when used exterior of a hospital setting by a non-physician
As a part of its assertion, the AMA really helpful that every one regulation enforcement and EMS responders be educated in “de-escalation strategies and the suitable use of pharmacological intervention for agitated people within the out-of-hospital setting.” Within the AMA’s view, topics who’re clearly experiencing psychological well being emergencies ought to be attended to by medical and behavioral well being professionals, not regulation enforcement.
Different teams reverse positions
In March 2023, the Nationwide Affiliation of Medical Examiners (NAME) made its place clear on the subject. In a assertion on its web site, the group mentioned that “[a]lthough the phrases ‘Excited Delirium’ or ‘Excited Delirium Syndrome’ have been utilized by forensic pathologists as a reason for dying prior to now, these phrases will not be endorsed by NAME or acknowledged in renewed classifications of the WHO, ICD-10, and DSM-V.”
The subsequent month, the American Faculty of Emergency Physicians (ACEP) reversed its place on the time period “excited delirium” to carry it according to the APA and the AMA, disavowing the usage of the time period “in medical settings.” ACEP continues to make use of the phrases “hyperactive delirium” and “hyperactive delirium syndrome with extreme agitation.”
The American Faculty of Medical Toxicology (ACMT) made a press release in Might 2023 recommending that its members “abandon the time period ‘excited delirium’ as a prognosis and a reason for dying.” Notably, the ACMT acknowledged the persevering with want for a time period to explain “sufferers with altered psychological standing who’re aggressive or have very important indicators suggestive of extreme adrenergic exercise.” The group advocated for the time period “hyperactive delirium with agitation,” mentioning that de-escalation strategies (typically involving sedatives) would nonetheless be needed for some topics. Bodily restraints, which have been so typically related to deaths in “excited delirium” sufferers, ought to be “minimized and discontinued as early as attainable.”
In October 2023, ACEP withdrew approval of its 2009 white paper, “Report on Excited Delirium Syndrome,” recommending that the time period “shouldn’t be used among the many wider medical and public well being group, regulation enforcement organizations, and ACEP members appearing as skilled witnesses testifying in related civil or legal litigation.” That is particularly notable as a result of ACEP’s 2009 paper was one of many most-cited sources to justify circumstances involving the situation. In accordance with an AP report printed by the Journal of Emergency Medical Companies, the white paper “formed police coaching and nonetheless figures in police custody dying circumstances, many involving Black males who died after being restrained by police.”
The identical month, the state of California handed a regulation banning the usage of “excited delirium” by coroners, medical experts and regulation enforcement in any experiences. The regulation, often known as AB 360, specifies that “excited delirium” shouldn’t be acknowledged as a legitimate medical situation or reason for dying within the state and proof that an individual skilled “excited delirium” is inadmissible in any civil motion. The regulation additionally made some extent of banning various phrases reminiscent of “hyperactive delirium,” “agitated delirium” and “exhaustive mania.”
Describe, don’t diagnose
Within the wake of the George Floyd case, many states and the District of Columbia enacted reforms to police procedures and oversight. Fairly just a few banned the usage of chokeholds and neck restraints by regulation enforcement. Transferring away from the usage of the time period “excited delirium” is an extension of those reform efforts. As famous, Lexipol eliminated the time period from our coverage steerage in 2022.
There isn’t any consensus on an alternate time period to make use of for the now-discontinued phrases. A part of that is because of the doubtful nature of the “syndrome” itself. “Excited delirium” was by no means acknowledged within the medical literature as an precise psychological dysfunction, and anyway, first responders aren’t educated or certified to diagnose and deal with psychological problems.
Legislation enforcement and EMS personnel will proceed to be known as upon to help with folks exhibiting extraordinarily violent, confused habits. Due to this, it’s really helpful that first responders keep away from any medical-sounding jargon and give attention to precise noticed habits. In radio site visitors, in experiences and in public statements, it’s finest to explain the habits exhibited by the topic. A number of examples:
- “Topic had stripped to his underwear and was shouting at and trying to punch anybody who got here close to him.”
- “The topic was aggressive and combative, kicking and spitting and cursing as officers tried to speak to him with a view to calm him down.”
- “The topic was extraordinarily agitated, respiration quickly and sweating profusely, and was noticed by officers making an attempt to smash the home windows of vehicles parked on the road along with his naked fists.”
Specializing in noticed habits moderately than quasi psychological phrases will assist shield each the people needing help and the regulation enforcement officers responding to the state of affairs, whereas additionally enhancing public security reporting and practices.
For extra details about this subject, together with suggestions on strategies to assist shield the protection of each topics and regulation enforcement officers, please see Lexipol’s article, “Understanding Excited Delirium: 4 Takeaways for Legislation Enforcement Officers.”
