Sudden Death in Custody: Is Excited Delirium Real?
The diagnosis of “excited delirium” is very controversial, especially to the extent it is used as an explanation for the death of individuals in law enforcement custody.
While leading emergency medical organizations (ACEP & NAEMSP) have in the past issued statements recognizing “excited delirium” as a valid diagnosis, more recently the leading US medical and psychiatric societies (AMA & APA) have taken a strong stance AGAINST the recognition of “excited delirium,” arguing that it has too often been used as a justification or explanation for deaths that were precipitated by physical restraint, complicated at times by substance-abuse or other factors.
The American Medical Association:
“Believes the current evidence does not support “excited delirium” or “excited delirium syndrome” as a medical diagnosis and opposes the use of the terms until a clear set of diagnostic criteria are validated.”
“Is concerned about law enforcement officer use of force accompanying “excited delirium” that leads to disproportionately high mortality among communities of color, particularly among Black men, and denounces “excited delirium” solely as a justification for the use of force by law enforcement officers.”
With regard to excited delirium (ExD), there is “a lack of:
a universally recognized definition
a clear understanding of pathophysiologic mechanisms, or
a specific diagnostic test
Deaths attributed to ExD have no consistent anatomical findings, resulting in ExD diagnosis being one of exclusion.
Studies have … indicated that a diagnosis of ExD and potentially fatal restraint are ‘inextricably interwoven.’
Restraint was described in 90 percent of all ExD deaths, making it the most common factor that is a plausible cause or contributing cause of the death.
There is no evidence to support ExD as a cause of death in the absence of restraint.
The autopsy results for individuals in which law enforcement officers cited ExD as the cause of death provide examples of this:
“excited delirium” noted as cause of death although a stun gun was utilized 4 times resulting in loss of consciousness;
cause of death listed as “undetermined,” although carotid hold and excessive restraint were utilized;
cause of death reported as “hypoxia due to physical restraint;”
died from “asphyxia due to neck and back compression;” and
death was due to “complications of asphyxia in the setting of physical restraint.”
The individuals most likely to be disproportionately identified as experiencing ExD, and to die from resulting first responder actions, or as a consequence of administration of chemical sedation for a presumed case of ExD, are:
otherwise healthy Black males in their mid-30s who are viewed as aggressive, impervious to pain, displaying bizarre behavior, and using substances –
characterizations that may be based less on evidence and more on generalizations, misconceptions, bias, and racism.
The identification of ExD has frequently been used in defense cases of law enforcement violence, despite reported autopsy results listing asphyxiation as the cause of death.”
“‘Excited delirium is a term that covers up more than it reveals,’ said Dr. Paul S. Appelbaum, past president of the American Psychiatric Association. ‘It pretends to be an explanation, but it just takes the place of a real explanation’ for what a patient may be experiencing, which may include underlying medical conditions, substances in their systems, fear of the encounter with police, or any combination of factors.”