Excited delirium

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Excited delirium is a condition that manifests as a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength.[1][2] Excited delirium is sometimes called excited delirium syndrome if it results in sudden death (usually via cardiac or respiratory arrest), an outcome that is sometimes associated with the use of physical control measures, including police restraint.[1][2] Excited delirium arises most commonly in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine.[1][3] Alcohol withdrawal or head trauma may also contribute to the condition.[4]

The diagnosis of excited delirium has been controversial.[5][6] Excited delirium has been listed as a cause of death by some medical examiners for several years,[7][8] mainly as a diagnosis of exclusion established on autopsy.[1] Additionally, academic discussion of excited delirium has been largely confined to forensic science literature, providing limited documentation about patients that survive the condition.[1] These circumstances have led some civil liberties groups to question the cause of death diagnosis, claiming that excited delirium has been used to "excuse and exonerate" law enforcement authorities following the death of detained subjects, a possible "conspiracy or cover-up for brutality" when restraining agitated individuals.[1][5][6] Also contributing to the controversy is the role of taser use in excited delirium deaths.[3][9] The American College of Emergency Physicians has officially recognized excited delirium as a unique syndrome[10] and "rejects the theory" that excited delirium is an "invented syndrome" used to excuse or cover-up the use of excessive force by law enforcement.[11] However, it has not been recognized as a medical or psychiatric diagnosis according to either the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) of the American Psychiatric Association or the International Classification of Diseases of the World Health Organization.[12]

Pathophysiology and symptoms

"Excited delirium" was first explicitly described in 1985 as a condition relating to acute cocaine intoxication.[4][13]

Prior to this it was referred to as "Bell's Mania"; first described by Luther Bell in 1849.[14]

The pathophysiology of excited delirium has been unclear,[10] but likely involves multiple factors.[15] These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal cardiac arrhythmias.[15]

A substantial majority of fatal case reports involved men, most commonly African American.[2][10] Excited delirium patients commonly have acute drug intoxication, generally psychostimulants such as cocaine, PCP and methamphetamine.[2]

The signs and symptoms for excited delirium may include:[2][4][10][16][17]

  • Paranoia
  • Disorientation
  • Hyper-aggression
  • Tachycardia
  • Hallucination
  • Incoherent speech or shouting
  • Seemingly superhuman strength or endurance (typically while trying to resist restrain efforts)
  • Hyperthermia (overheating)/profuse sweating (even in cold weather)
  • Inappropriately clothed e.g. having removed garments

Other medical conditions that can resemble excited delirium are panic attack, hyperthermia, diabetes, head injury, delirium tremens, and hyperthyroidism.[18]

Controversy

Lack of classification in DSM

Excited delirium is not found in the current version of the Diagnostic and Statistical Manual of Mental Disorders. Eric Balaban of the American Civil Liberties Union argued in 2007 that excited delirium was not recognized by the American Medical Association or the American Psychological Association and that the diagnosis served "as a means of white-washing what may be excessive use of force and inappropriate use of control techniques by officers during an arrest."[5] Melissa Smith of the American Medical Association stated in 2007 that the organization had "no official policy" on the condition.[6]

However the term "excited delirium" has been accepted by the National Association of Medical Examiners and the American College of Emergency Physicians, who argued in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9.[1]

Use to exonerate police restraint and TASER use

Some civil-rights groups argue that excited delirium diagnoses are being used to absolve law enforcement of guilt in cases where alleged excessive force may have contributed to patient deaths.[19][20][21] In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.[21]

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 electronic weapon. He called "excited delirium" a "dubious disorder" used by Taser International in its training of police.[22] In a 2008 report entitled An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police, the authors 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.[23]

A 2010 systematic review published in the Journal of Forensic and Legal Medicine argued that the symptoms associated with excited delirium likely posed a far greater medical risk than the use of tasers, and that it seems unlikely that taser use significantly exacerbates the symptoms of excited delirium.[24]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 "White Paper Report on Excited Delirium Syndrome", ACEP Excited Delirium Task Force, American College of Emergency Physicians, September 10, 2009
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR (March 2009). "Excited delirium deaths in custody: past and present". Am J Forensic Med Pathol 30 (1): 1–5. doi:10.1097/PAF.0b013e31818738a0. PMID 19237843. 
  3. ↑ 3.0 3.1 Ruth SoRelle (October 2010). "ExDS Protocol Puts Clout in EMS Hands". Emergency Medicine News 32 (10): 1, 32. doi:10.1097/01.EEM.0000389817.48608.e4. 
  4. ↑ 4.0 4.1 4.2 Samuel E, Williams RB, Ferrell RB (2009). rticle_id=2807 "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatr Dis Treat 5: 61–6. PMC 2695211. PMID 19557101. 
  5. ↑ 5.0 5.1 5.2 "Death by Excited Delirium: Diagnosis or Coverup?". NPR. Retrieved 2007-02-26. "You may not have heard of it, but police departments and medical examiners are using a new term to explain why some people suddenly die in police custody. It's a controversial diagnosis called excited delirium. But the question for many civil liberties groups is, does it really exist?" 
  6. ↑ 6.0 6.1 6.2 "Excited Delirium: Police Brutality vs. Sheer Insanity". ABC News. March 2, 2007. Retrieved 2007-03-13. "Police and defense attorneys are squaring off over a medical condition so rare and controversial it can't be found in any medical dictionary — excited delirium. Victims share a host of symptoms and similarities. They tend to be overweight males, high on drugs, and display extremely erratic and violent behavior. But victims also share something else in common. The disorder seems to manifest itself when people are under stress, particularly when in police custody, and is often diagnosed only after the victims die." 
  7. ↑ "Suspects' deaths blamed on 'excited delirium'. Critics dispute rare syndrome usually diagnosed when police are involved". Associated Press at MSNBC. Retrieved 2007-04-29. "Excited delirium is defined as a condition in which the heart races wildly — often because of drug use or mental illness — and finally gives out. Medical examiners nationwide are increasingly citing the condition when suspects die in police custody. But some doctors say the rare syndrome is being overdiagnosed, and some civil rights groups question whether it exists at all." 
  8. ↑ "Excited delirium, not Taser, behind death of N.S. man: medical examiner". The Canadian Press. September 17, 2008. Retrieved 2008-10-13. "Medical examiner Dr. Matthew Bowes concluded that Hyde died of excited delirium due to paranoid schizophrenia. He said Hyde's coronary artery disease, obesity and the restraint used by police during a struggle were all factors in his death. ... In a government news release, excited delirium is described as a disorder characterized by extreme agitation, violent and bizarre behaviour, insensitivity to pain, elevated body temperature, and superhuman strength. It says not all of these characterizations are always present in someone with the disorder." 
  9. ↑ "Tasers Implicated in Excited Delirium Deaths". NPR. Retrieved 2007-04-29. "The medical diagnosis called excited delirium is the subject of intense debate among doctors, law-enforcement officers and civil libertarians. They don't even all agree on whether the condition exists. But to Senior Cpl. Herb Cotner of the Dallas Police Department, there's no question that it's real." 
  10. ↑ 10.0 10.1 10.2 10.3 Lisa Hoffman (November 2009). "ACEP Recognizes Excited Delirium as Unique Syndrome". Emergency Medicine News 31 (11): 4. doi:10.1097/01.EEM.0000340950.69012.8d. 
  11. ↑ Mark L. DeBard, MD (November 2009). "Identifying New Disease as Excited Delirium Syndrome Rejects Idea that Police Brutality Causes Deaths". Emergency Medicine News 31 (11): 3, 5. doi:10.1097/01.EEM.0000340950.69012.8d. "The report has some political implications, too, because it rejects the theory that ExDS is an invented syndrome being used to cover up or excuse the use of force or even brutality by law enforcement officers when someone dies in their custody. It rejects the idea that specific forms of restraint in and of themselves are what cause deaths in ExDS patients. Instead, ExDS is a potentially fatal disease in which all forms of physiologic stress, from physical and noxious chemical to electrical conductive weapons (commonly called TASERs), can tip the balance of a condition on the edge of being fatal. It recognizes that some form of the use of force will often be necessary to control agitation in the face of delirium, but that it should be the minimal amount necessary to achieve patient control and ensure public safety, and be followed immediately by medical intervention." 
  12. ↑ Takeuchi A, Ahern T, Henderson S (February 2011). "Excited Delirium". WestJEM 12 (1): 77–83. PMC 3088378. PMID 21691475. 
  13. ↑ Wetli CV, Fishbain DA (July 1985). "Cocaine-induced psychosis and sudden death in recreational cocaine users". J. Forensic Sci. 30 (3): 873–80. PMID 4031813. 
  14. ↑ Kraines. "Bell's Mania". The American Journal of Psychiatry. 
  15. ↑ 15.0 15.1 Otahbachi M, Cevik C, Bagdure S, Nugent K (June 2010). "Excited delirium, restraints, and unexpected death: a review of pathogenesis". Am J Forensic Med Pathol 31 (2): 107–12. doi:10.1097/PAF.0b013e3181d76cdd. PMID 20190633. 
  16. ↑ Alan W. Benner, Excited Delirium, 1996
  17. ↑ "Excited Delirium.org: For Law Enforcement". University of Miami. Retrieved 2011-07-01. 
  18. ↑ "What other medical emergencies can look like excited delirium?". PoliceOne.com. October 2006. Retrieved 2007-03-26. 
  19. ↑ Truscott A (March 2008). "A knee in the neck of excited delirium". CMAJ 178 (6): 669–70. doi:10.1503/cmaj.080210. PMC 2263095. PMID 18332375. 
  20. ↑ Paquette M (2003). "Excited delirium: does it exist?". In Paquette, Mary. Perspect Psychiatr Care 39 (3): 93–4. doi:10.1111/j.1744-6163.2003.00093.x. PMID 14606228. 
  21. ↑ 21.0 21.1 "'Excited delirium' as a cause of death", Daniel Costello, Los Angeles Times, April 21, 2003
  22. ↑ Hall, Neil (2008-05-14). "Police are 'brainwashed' by Taser maker; Psychologist blames instructions". Vancouver Sun (Canwest). pp. A1. Retrieved 2008-08-30. 
  23. ↑ "An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police", John Kiedrowski, Royal Canadian Mounted Police, June 5, 2008
  24. ↑ Jauchem JR (January 2010). "Deaths in custody: are some due to electronic control devices (including TASER devices) or excited delirium?". J Forensic Leg Med 17 (1): 1–7. doi:10.1016/j.jflm.2008.05.011. PMID 20083043. 

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