Excited delirium
Encyclopedia
Excited delirium is a condition that manifests as a combination of delirium
, psychomotor agitation
, anxiety
, hallucination
s, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain
, elevated body temperature, and superhuman strength. 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 and taser
s. 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
. Alcohol withdrawal or head trauma may also contribute to the condition.
The diagnosis of excited delirium has been controversial. Excited delirium has been listed as a cause of death
by some medical examiner
s for several years, mainly as a diagnosis of exclusion
established on autopsy
. Additionally, academic discussion of excited delirium has been largely confined to forensic science literature, providing limited documentation about patients that survive the condition. 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. Also contributing to the controversy is the role of taser use in excited delirium deaths. The American College of Emergency Physicians
has officially recognized excited delirium as a unique syndrome 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.
Prior to this it was referred to as "Bell's Mania"; first described by Luther Bell in 1849.
The pathophysiology
of excited delirium has been unclear, but likely involves multiple factors. These may include positional asphyxia
, hyperthermia
, drug toxicity, and/or catecholamine
-induced fatal cardiac arrhythmias.
A substantial majority of fatal case reports involved men, most commonly African American
. Excited delirium patients commonly have acute drug intoxication, generally psychostimulants such as cocaine
, PCP
and methamphetamine
.
The signs and symptoms for excited delirium may include:
Other medical conditions that can resemble excited delirium are panic attack
, hyperthermia
, diabetes, head injury
, delirium tremens
, and hyperthyroidism
.
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 syptoms of excited delirium.
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." Melissa Smith of the American Medical Association stated in 2007 that the organization had "no official policy" on the condition. Excited delirium is not found in the current version of the Diagnostic and Statistical Manual of Mental Disorders
, though 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.
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. 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.
Delirium
Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior...
, psychomotor agitation
Psychomotor agitation
Psychomotor agitation is a series of unintentional and purposeless motions that stem from mental tension and anxiety of an individual. This includes pacing around a room, wringing one's hands, pulling off clothing and putting it back on and other similar actions...
, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, hallucination
Hallucination
A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid,...
s, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
, elevated body temperature, and superhuman strength. Excited delirium is sometimes called excited delirium syndrome if it results in sudden death (usually via cardiac
Cardiac arrest
Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
or respiratory arrest
Respiratory arrest
Respiratory arrest is the cessation of breathing. It is a medical emergency and it usually is related to or coincides with a cardiac arrest. Causes include opiate overdose, head injury, anaesthesia, tetanus, or drowning...
), an outcome that is sometimes associated with the use of physical control measures, including police restraint and taser
Taser
A Taser is an electroshock weapon that uses electrical current to disrupt voluntary control of muscles. Its manufacturer, Taser International, calls the effects "neuromuscular incapacitation" and the devices' mechanism "Electro-Muscular Disruption technology"...
s. Excited delirium arises most commonly in male subjects with a history of serious mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
and/or acute or chronic drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
, particularly stimulant drugs such as cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
. Alcohol withdrawal or head trauma may also contribute to the condition.
The diagnosis of excited delirium has been controversial. Excited delirium has been listed as a cause of death
Cause of Death
Cause of Death is a 1990 album by American death metal band Obituary. Cause of Death is considered a classic album in the history of death metal. The artwork was done by artist Michael Whelan...
by some medical examiner
Medical examiner
A medical examiner is a medically qualified government officer whose duty is to investigate deaths and injuries that occur under unusual or suspicious circumstances, to perform post-mortem examinations, and in some jurisdictions to initiate inquests....
s for several years, mainly as a diagnosis of exclusion
Diagnosis of exclusion
A diagnosis of exclusion is a medical condition reached by a process of elimination, which may be necessary if presence cannot be established with complete confidence from examination or testing...
established on autopsy
Autopsy
An autopsy—also known as a post-mortem examination, necropsy , autopsia cadaverum, or obduction—is a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present...
. Additionally, academic discussion of excited delirium has been largely confined to forensic science literature, providing limited documentation about patients that survive the condition. These circumstances have led some civil liberties
Civil liberties
Civil liberties are rights and freedoms that provide an individual specific rights such as the freedom from slavery and forced labour, freedom from torture and death, the right to liberty and security, right to a fair trial, the right to defend one's self, the right to own and bear arms, the right...
groups to question the cause of death
Cause of Death
Cause of Death is a 1990 album by American death metal band Obituary. Cause of Death is considered a classic album in the history of death metal. The artwork was done by artist Michael Whelan...
diagnosis, claiming that excited delirium has been used to "excuse and exonerate" law enforcement
Law enforcement agency
In North American English, a law enforcement agency is a government agency responsible for the enforcement of the laws.Outside North America, such organizations are called police services. In North America, some of these services are called police while others have other names In North American...
authorities following the death of detained subjects, a possible "conspiracy or cover-up for brutality" when restraining agitated individuals. Also contributing to the controversy is the role of taser use in excited delirium deaths. The American College of Emergency Physicians
American College of Emergency Physicians
The American College of Emergency Physicians is the first and largest professional organization of emergency medicine physicians in the United States. It was founded in 1968 and is now headquartered in Irving, Texas. As of 2009 ACEP has over 28,000 physician members.The college exists to support...
has officially recognized excited delirium as a unique syndrome 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.
Pathophysiology and symptoms
"Excited delirium" was first explicitly described in 1985 as a condition relating to acute cocaine intoxication.Prior to this it was referred to as "Bell's Mania"; first described by Luther Bell in 1849.
The pathophysiology
Pathophysiology
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome...
of excited delirium has been unclear, but likely involves multiple factors. These may include positional asphyxia
Positional asphyxia
Positional asphyxia, also known as postural asphyxia, is a form of asphyxia which occurs when someone's position prevents them from breathing adequately. A small but significant number of people die suddenly and without apparent reason during restraint by police, prison officers and health care...
, hyperthermia
Hyperthermia
Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate...
, drug toxicity, and/or catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
-induced fatal cardiac arrhythmias.
A substantial majority of fatal case reports involved men, most commonly African American
African American
African Americans are citizens or residents of the United States who have at least partial ancestry from any of the native populations of Sub-Saharan Africa and are the direct descendants of enslaved Africans within the boundaries of the present United States...
. Excited delirium patients commonly have acute drug intoxication, generally psychostimulants such as cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
, PCP
Phencyclidine
Phencyclidine , commonly initialized as PCP and known colloquially as angel dust, is a recreational dissociative drug...
and methamphetamine
Methamphetamine
Methamphetamine is a psychostimulant of the phenethylamine and amphetamine class of psychoactive drugs...
.
The signs and symptoms for excited delirium may include:
- ParanoiaParanoiaParanoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...
- Disorientation
- Hyper-aggression
- TachycardiaTachycardiaTachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
- HallucinationHallucinationA hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid,...
- Incoherent speech or shouting
- Incredible strength or endurance (typically noticed during attempts to restrain victim)
- HyperthermiaHyperthermiaHyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate...
(overheating)/profuse sweating (even in cold weather)
Other medical conditions that can resemble excited delirium are panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
, hyperthermia
Hyperthermia
Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate...
, diabetes, head injury
Head injury
Head injury refers to trauma of the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in medical literature....
, delirium tremens
Delirium tremens
Delirium tremens is an acute episode of delirium that is usually caused by withdrawal from alcohol, first described in 1813...
, and hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
.
A 2010 systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
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 syptoms of excited delirium.
Society and culture
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. In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.Eric Balaban of the American Civil Liberties Union
American Civil Liberties Union
The American Civil Liberties Union is a U.S. non-profit organization whose stated mission is "to defend and preserve the individual rights and liberties guaranteed to every person in this country by the Constitution and laws of the United States." It works through litigation, legislation, and...
argued in 2007 that excited delirium was not recognized by the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
or the American Psychological Association
American Psychological Association
The American Psychological Association is the largest scientific and professional organization of psychologists in the United States. It is the world's largest association of psychologists with around 154,000 members including scientists, educators, clinicians, consultants and students. The APA...
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." Melissa Smith of the American Medical Association stated in 2007 that the organization had "no official policy" on the condition. Excited delirium is not found in the current version of the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
, though the term "excited delirium" has been accepted by the National Association of Medical Examiners and the American College of Emergency Physicians
American College of Emergency Physicians
The American College of Emergency Physicians is the first and largest professional organization of emergency medicine physicians in the United States. It was founded in 1968 and is now headquartered in Irving, Texas. As of 2009 ACEP has over 28,000 physician members.The college exists to support...
, who argued in a 2009 white paper
White paper
A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...
that "excited delirium" may be described by several codes within the ICD-9.
In Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
, 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
British Columbia
British Columbia is the westernmost of Canada's provinces and is known for its natural beauty, as reflected in its Latin motto, Splendor sine occasu . Its name was chosen by Queen Victoria in 1858...
inquiry into taser deaths that police have been "brainwashed" by Taser International
TASER International
Taser International, Inc. is a developer, manufacturer, and distributor of the Taser less-lethal electroshock guns in the United States. It is based at Scottsdale, Arizona, United States. Taser is the most common brand of electroshock gun.-History:...
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. 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
Royal Canadian Mounted Police
The Royal Canadian Mounted Police , literally ‘Royal Gendarmerie of Canada’; colloquially known as The Mounties, and internally as ‘The Force’) is the national police force of Canada, and one of the most recognized of its kind in the world. It is unique in the world as a national, federal,...
without formal approval after consultation with a mental-health-policy advisory body.
See also
- Electroshock weapon controversy
- Positional asphyxiaPositional asphyxiaPositional asphyxia, also known as postural asphyxia, is a form of asphyxia which occurs when someone's position prevents them from breathing adequately. A small but significant number of people die suddenly and without apparent reason during restraint by police, prison officers and health care...
- Sudden unexpected nocturnal death syndrome
- Delirium tremensDelirium tremensDelirium tremens is an acute episode of delirium that is usually caused by withdrawal from alcohol, first described in 1813...
External links
- http://www.emsonline.net/street2008/skillsvideos/edvid.html Video of an 'excited delirium' incident- police contact, suspect/patient restraint, CPR, and paramedic arrival at incident
- Is 'excited delirium' at the root of many Taser deaths? CBC News report by Armina Ligaya (2007).
- Taser firms picked up coroner's lecture tab The Globe & Mail (2007).
- Symposium aims to define 'excited delirium' The Globe & Mail (2007).
- Filings with S.E.C. & class actions for allegedly failing to disclose and misrepresention on safety.
- Taser manufacturer's view
- Excited Delirium Medical research review at the Canadian Police Research Centre
- Excited Delirium": A Two-Fold Problem S. Marshall Isaacs, M.D., San Francisco Department of Health, Paramedic Division, San Francisco, California
- http://www.exciteddelirium.org/indexPublicationshtml.html Bell LV (1849) On a form of disease resembling some advanced stages of mania and fever. Am. J. Insanity 6:97-127.
- The Institute For Prevention of In-Custody Deaths IPICD, Inc. is the global leader for training in excited delirium, agitated chaotic events, arrest-related deaths, and forensic investigations.