Excited Delirium: A Fatal Term Laid to Rest

Excited delirium, a diagnosis generally characterized by a severely agitated state, made headlines in some of the most contentious deaths in custody, including being mentioned by an officer as a concern when George Floyd was in a prolonged prone position. Law enforcement officers have been trained to recognize excited delirium as a medical emergency requiring immediate medical intervention when someone shows extreme agitation, incoherent speech, increased pain with decreased sensitivity to pain, confusion or rapid changes in emotion, and muscle rigidity. Once the person is in custody or restrained, training outlined putting the person into the recovery position to avoid positional asphyxiation and awareness that sudden death can occur after a violent struggle. Autopsies in excited delirium cases generally reveal lung and brain swelling coupled with heart disease and recent cocaine use without providing a direct cause of death. The lack of clear signs of death during an autopsy requires forensic pathologists to relate known circumstances to the cardiovascular collapse.

History of a Controversial Term

The controversy around the use of excited delirium as a cause of death is that it was not formally recognized as a distinct medical diagnosis by many of the top medical associations, including the World Health Organization, the American Medical Association (AMA), and the American Psychiatric Association. The disputable cause of death has never been formally recognized in the Diagnostic and Statistical Manual (DSM), a guide to symptom diagnosis for mental health conditions, or the International Classification of Diseases (ICD), a guide to diseases and conditions to assist with classification and statistics tracking published by the World Health Organization. The lack of an ICD code dramatically reduces the ability to track the diagnosis in fatal and non-fatal circumstances. The American College of Emergency Physicians was the only medical organization that formally supported the diagnosis of excited delirium and its clinical use. The ACEP confirmed their support for the excited delirium diagnosis in 2021 and formally retracted their support for using the terminology in April 2023. The National Association of Medical Examiners does not endorse the use of excited delirium as a cause of death and recommends using underlying causes of the suspected delirium as the cause of death.

The history of excited delirium was first noted in the 19th century with the term delirious mania, with someone suffering from hyperactivity, psychosis, and sudden collapse. Other psychiatrists across the world added to the body of research and changed the mania phraseology, with excited delirium being coined in 1985 by an American forensic pathologist and psychiatrist to describe a person with superhuman strength, extreme fear and paranoia, hyperthermia, agitation, and generally involving recent cocaine use. Through the eyes of a forensic pathologist, there was no specific anatomic cause of death but a process of ruling out causes of death, such as in sudden unidentified infant death syndrome. In their seminal work, Drs. Welti and Fishbain reviewed seven case studies with cocaine involved with all and the decedents being hyperactive, violent, yelling, and thrashing around. Six of the seven case studies had increased strength, and all required restraints to reduce the violence. A 1998 review of 21 excited delirium deaths in Ontario, Canada, showed that all cases involved restraint for violence and hyperactivity with 18 people being in the prone position and three having pressure placed on their necks at the time of death, suggesting that the position of restraint may be directly related to the death and not the excited delirium itself. At least 166 deaths in police custody from 2010-2020 were attributed to excited delirium across the nation, though required reporting through the 2013 Death in Custody Reporting Act is complicated with data collection and antiquated reporting mechanisms.

The AMA noted that excited delirium was not a supported medical diagnosis and condemned the potential recognition of excited delirium as the sole reason for law enforcement officers to use excessive force. The AMA recognized that excited delirium has been disproportionately used in diagnoses for in-custody deaths of underrepresented minorities and misused to justify police actions. The 2021 policy also recommended utilizing non-law enforcement practitioners for de-escalation efforts and appropriate medication intervention, further recognizing racism as a threat to public health. One of the physicians who coined the term excited delirium completed a review of sex workers with a recreational drug use history and suggested that the deaths were due to a variant of excited delirium. All of the sex workers were Black women, and exhumations of some decedents after the forensic pathologist’s cause of death attribution to excited delirium was incorrect as the decedents were strangled to death, later leading to the arrest of a serial killer.

Citing Proper Cause of Death Classification

California banned the use of an excited delirium diagnosis as a cause of death, in medical treatments, police reports, and court proceedings. Assembly Bill 360 updated the California Evidence Code to state that excited delirium is not a valid cause of death or medical diagnosis but that descriptions of behavioral signs and symptoms can be stated in police reports and civil actions. The bill was signed into law in October 2023, marking the first state in the union to restrict the use of excited delirium. Some law enforcement agencies in California, in advance of the ban, removed the controversial term from policies and training material to focus on racial equity. Colorado’s Peace Officer Standards and Training, a law enforcement certifying board, will be removing excited delirium from law enforcement training starting on January 1, 2024. The updated training curriculum will focus on providing care to subjects in custody and requesting appropriate levels of care.

While the banning of the term excited delirium is logical based on its history and unsupported medical research, there are concerns about the government restricting medical professionals from being able to properly diagnose and classify their work. The Texas Governor signed HB 6 into law in June 2023, classifying all opioid toxicity-related deaths as poisonings to allow for homicide charges against those who manufacture and sell illegal drugs. California had its first successful prosecution of a drug dealer who sold a fentanyl-laced pill to a decedent in August 2023. However, there is no evidence that prosecutions for drug toxicity-related deaths are a deterrent to drug use or save lives. Texas did not pass the legalization of fentanyl test strips, allowing people to test their drugs for the presence of fentanyl prior to ingestion. Dictating exact wording for death certificates, such as “fentanyl poisoning” for opioid-related deaths may be the start of a slippery slope for laws restricting medical expertise and diagnoses.

History has been made to bar the use of excited delirium in medical and law enforcement settings, though recognizing medical and psychiatric emergencies is vitally important for the person in crisis to receive appropriate treatment. When someone shows signs of extreme agitation, incoherent speech, confusion, and paranoia, activating the emergency 9-1-1 system is essential to reducing mortality. Law enforcement officers should follow appropriate policies and procedures for deescalating and obtaining immediate care and referrals to mental health professionals to increase survival and recovery through crisis events.