Excited delirium

Throughout the 19th and early-20th century, "excited delirium" was used to describe an emotional and agitated state related to drug overdose and withdrawal or poisonings, similar to catatonia or Bell's mania, with some believing them to be the same condition. In 1985, an article titled "Cocaine-induced psychosis and sudden death in recreational cocaine users", co-authored by Dade County deputy chief medical examiner Charles Victor Wetli was published in the Journal of Forensic Sciences. The article describes a state of "excited delirium" in cocaine users leading to respiratory collapse and death, despite the people having blood concentrations of cocaine ten times lower than those seen in fatal overdoses. In five of the seven cases presented in the article, the deaths occurred while in police custody. In 1988, Wetli claimed that a series of nineteen women, all Black prostitutes, had died of excited delirium due to "sexual excitement" while under the influence of cocaine. Police later announced they had found a serial killer, Charles Henry Williams, responsible for those deaths. By the 1990s, the term "excited delirium" (ExDS) began to be used as a diagnosis to explain deaths in police custody especially during or after restraint, particularly in Florida. Despite the increasing usage of "excited delirium" in the 1990s by some medical examiners and police, mainstream medical associations refused to recognize the legitimacy of the purported syndrome, and it was never listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the early 2000s, medical commentators noted that excited delirium was used disproportionately against African Americans, and alleged that police often used it to cover up deaths resulting from police brutality while in custody. Rejection by experts Excited delirium is not recognized by the World Health Organization, the American Psychiatric Association, the American Medical Association, and not listed as a medical condition in the Diagnostic and Statistical Manual of Mental Disorders Dr. Michael Baden, a specialist in investigating deaths in custody, describes excited delirium as "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". In June 2021, the Royal College of Psychiatrists in the UK released a statement that they do "not support the use of such terminology [as ExDS or AgDS], which has no empirical evidential basis" and said "the use of these terms is, in effect, racial discrimination". A 2020 scientific literature review looked at reported cases of excited delirium and agitated delirium. The authors noted that most published current information has indicated that excited delirium-related deaths are due to an occult pathophysiologic process. A database of cases was created which included the use of force, drug intoxication, mental illness, demographics, and survival outcome. A review of cases revealed there was no evidence to support ExDS as a cause of death in the absence of restraint. The authors found that when death occurred in an aggressively restrained individual that fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered the more likely cause of the death. Position of the American College of Emergency Physicians Prior to 2009, excited delirium was only recognized by medical examiners, not physicians. However, in 2009, a 19-person task force from American College of Emergency Physicians (ACEP) wrote a white paper suggesting that excited delirium should be considered as a valid syndrome, which physicians can use for diagnoses. This suggestion was adopted by the ACEP later in 2009. In 2017, investigative reporters from Reuters reported that three of the 19 members of the 2009 task force were paid consultants for Axon, the manufacturer of Tasers. In a statement, the ACEP said it had "withdrawn its approval of this [the 2009] paper" and that "[t]he term excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation". ==Controversy==

Association with racism In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites, and the American Psychiatric Association also notes that "the term excited delirium is disproportionately applied to Black men in police custody". Several academic commentators have noted that medical personnel and law enforcement personnel apply diagnoses of excited delirium in a manner which disproportionately disadvantages African Americans. Excited delirium has also been used to diagnose Indigenous people after violent police encounters. In 1999, in Victoria British Columbia, Canada, Anthany Dawson, a member of the Musgamagw Tsawataineuk Nation, was beaten and punched repeatedly by the police before dying in an ambulance. Initially, police statements relayed to the public that overdose was his cause of death, though there was no evidence of drug use at the time of the statements’ release. Later, toxicology reports only found a small amount of marijuana from the previous evening before his death. In the media, Dawson was portrayed as having been mentally ill, but he had no medical history of mental illness. Then, he was believed to have a genetic condition that predisposed him to die of excited delirium which was the documented cause of his death. Dawson's mother, however, maintains that "police force and racism" was the sole cause of her son’s death. Rather than enacting empathy and compassion for people in vulnerable situations, the police create a dehumanizing narrative wherein the victims’ death is inevitable, where their life reaches a prescribed end. Police procedures and behaviours, their tendency to escalate force and gross neglect goes unexamined and unquestioned. Ultimately, it removes moral culpability and accountability from the police and leaves the victims’ families and communities without justice nor a proper account of their loved ones’ death. Excited delirium has been described as fundamentally racist by many commentators in the media, including Jon Ronson's BBC podcast Things Fell Apart in 2024. The episode, titled "The Most Mysterious Deaths", describes Wetli's initial coining of the phrase "excited delirium", as well as the later debunking of the phenomenon, and its connection to the murder of George Floyd. Before the term "excited delirium" was rejected by the ACEP in 2023, its supposed risk factors vary including "bizarre behavior generating phone calls to police", "failure to respond to police presence", and "continued struggle despite restraint". It supposedly endows individuals with "superhuman strength" and being "impervious to pain". It is disproportionately diagnosed among young Black men, and has clear undertones of racial bias. Influence of Taser manufacturer Axon Enterprise, formerly Taser International, provides training for police on recognizing excited delirium and several prominent proponents of the diagnosis are retained by Axon, In Canada, the 2007 case of Robert Dziekanski received national attention and placed a spotlight on the use of tasers in police actions and the diagnosis of excited delirium. Police psychologist Mike Webster testified at a British Columbia inquiry into taser deaths that police have been "brainwashed" by Taser International to justify "ridiculously inappropriate" use of the electric weapon. He called excited delirium a "dubious disorder" used by Taser International in its training of police. In a 2008 report, the Royal Canadian Mounted Police argued that excited delirium should not be included in the operational manual for the Royal Canadian Mounted Police without formal approval after consultation with a mental-health-policy advisory body. Association with police restraint Amnesty International found that the syndrome was cited in 75 of the 330 deaths following police use of a taser on suspects between 2001 and 2008, While diagnosis is habitually of men under police restraint, medical preconditions and symptoms attributed to the syndrome are far more varied. Males account for more documented diagnoses than females. Often law enforcement has used tasers or physical measures in these cases, and death most frequently occurs after the person is forcefully restrained. Critics of excited delirium have stated that the condition is primarily attributed to deaths while in the custody of law enforcement and is disproportionately applied to Black and Hispanic victims. One study looking at cocaine-related deaths in the 1970s and 1980s in Florida, showed that the deaths were more likely to be diagnosed as excited delirium when involving young Black men dying in police custody and "accidental cocaine toxicity" when involving white people. A 1998 study found that "In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained". The UK Independent Advisory Panel on Deaths in Custody (IAP) suggests that the syndrome should be termed "Sudden death in restraint syndrome" in order to enhance clarity. Prosecutor Steve Schleicher refuted the defense suggestion that Floyd had "superhuman strength" during his arrest because he was suffering from the condition. Ketamine use Ketamine or midazolam and haloperidol injected into a muscle have frequently been used, sometimes at direct police request, to sedate people alleged to be experiencing excited delirium. Concern has been raised about the increasing usage of a claim of excited delirium to justify tranquilizing persons during arrest, with requests for tranquilization often being made by law enforcement rather than medical professionals. Ketamine is the most commonly used drug in these cases. There have been deaths related to use of ketamine on restrained prisoners. A controversial study into ketamine use was terminated due to ethics concerns. The study was also linked to Axon via Jeffrey Ho. He went into cardiac arrest a few minutes later. In a report of the case on 60 Minutes, John Dickerson interviewed the District Attorney who justified the use of ketamine, adding that since excited delirium could not be ruled out as a cause of death it would be impossible to win a homicide case because "you can't file a homicide charge without cause of death." == See also ==