Excited delirium: Understanding the evolution away from a … – Police News

For decades, law enforcement officers, medical examiners and emergency medical professionals have used the terms excited delirium and excited delirium syndrome to describe subjects experiencing extreme agitation, excitability, paranoia and aggression, often associated with stimulant use and certain psychiatric disorders. While officers continue to encounter subjects displaying such symptoms, the term excited delirium has come under significant scrutiny and is now disavowed by major medical and psychological organizations, including:

Lexipol removed the term excited delirium from our policy guidance in 2022. Regardless of your agencys policy on the use of this term, its helpful for law enforcement officers to understand why the medical community has evolved away from using it.

For well over a century, medical experts have used various terms to describe a condition in which subjects experience:

This condition has variously been labeled Bells mania, acute exhaustive mania, lethal catatonia and agitated delirium. In 1985, at the height of the U.S. crack cocaine epidemic, researchers Charles Wetli and David Fishbaindubbed the conditionexcited delirium, noting it often co-occurred with cocaine use (though typically at drug concentrations lower than seen in cases of cocaine overdose). The term was often shortened to EXD (for excited delirium) or ExDs (for excited delirium syndrome).

Areport on the topicin theWestern Journal of Emergency Medicinenoted that excited delirium and agitated delirium described a subject exhibiting agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. The report pointed out that about two thirds of EXD victims die at the scene or during transport by paramedics or police. Citing Wetli, the report noted those who died without contact with the police were often discovered in a bathroom after apparent attempts to cool their body temperature using wet towels and ice trays.

An article inForce Sciencestated the symptoms labeled as excited delirium can be caused by a number of very different medical conditions:

During the 2000s and 2010s, officers may have been taught to recognize and respond to excited delirium as part of academy and post-academy training. Over the years, guidance has changed. Early tactics often varied dramatically from agency to agency. As understanding of the risks of certain restraint positions became more widespread, guidance evolved to favor avoiding a prolonged struggle whenever possible. When a calm and deliberate approach proves ineffective, then the use of other restraints and control techniques (as opposed to pain compliance measures) is preferred.

Perhaps the most important guidance over the past decade or so has been the need for officers to recognize these subjects as experiencing a medical emergency, and call EMS as quickly as possible.

According to a2022 reportprepared by Physicians for Human Rights (PHR), multiple studies have suggested that diagnoses of excited delirium may have been used to justify excessive use of force by law enforcement. A look intoin-custody deaths in Texasfrom 2005 through 2017 showed that excited delirium was blamed for 17% of the 289 cases. Asimilar study in Floridademonstrated the same pattern: 85 deaths blamed on the condition over a period of 10 years.

After an extensive review of the literature and consultation with experts, the PHR report also concluded that the term excited delirium cannot be disentangled from its racist and unscientific origins. For example, a2021 articlein theVirginia Law Reviewrevealed that, of 166 in-custody deaths across the country, Black subjects made up over 43% of those with excited delirium listed as a possible cause of death. That percentage rose to 56% when Black and Hispanic subjects were combined.

It was after the 2020 death of George Floyd when many Americans may have first heard the term excited delirium. In the viral video that shocked the world, one of the responding officers mentioned the condition while another officer had Floyd in a prone position on the ground. That officer was later convicted of unintentional second-degree murder, third-degree murder and second-degree manslaughter. The officer who had mentioned the condition of excited delirium later pled guilty to aiding and abetting second-degree manslaughter.

In the wake of Floyds death and the subsequent demonstrations and unrest, many organizations including the American Psychiatric Association (APA) revisited their positioning on the use of excited delirium in police reports, coroners reports and news stories. In December 2020, the APA made the followingofficial statementon the use of the term:

It is the position of the American Psychiatric Association that acute medical conditions, including Delirium, always require an appropriate medical response. Therefore, it is the position of the APA that:

1. The term excited delirium (ExDs) is too non-specific to meaningfully describe and convey information about a person. Excited delirium should not be used until a clear set of diagnostic criteria are validated.

2. An investigation should be undertaken of cases labelled with excited delirium to identify how the term is being used, whether consistent criteria are being applied, and whether it has any validity as a medical syndrome. The U.S. Department of Health and Human Services should conduct a comprehensive, nationwide investigation of instances in which individuals have been identified as being in a state of excited delirium, including in interactions with law enforcement personnel and other out-of-hospital contexts. The study should include examination of all relevant data, including the precipitating events, health outcomes for the individuals and law enforcement personnel, and whether there is a disproportionate application of the term excited delirium to persons with mental illness, Black people, or other racial and ethnic groups.

3. All jurisdictions should develop, implement, and routinely update evidence-based protocols for the administration of ketamine and other sedating medications in emergency medical contexts outside the hospital. These protocols should allow use of these medications only for treatment purposes in medically appropriate situations and should explicitly bar their use to achieve incapacitation solely for law enforcement purposes.

The APA pointed out that theDSM-5, the most current update to theDiagnostic and Statistical Manual of Mental Disorders, does not list excited delirium as an actual psychological condition. It also points out that EMTs routinely treated subjects suspected of having EXD withketamine, which has the potential to cause respiratory arrest. Because of this, the APA says, it is questionable whether the person identified as having an excited delirium actually had any medical condition warranting its use.

Half a year later, in June 2021, the American Medical Association (AMA) put out its ownpress releasestating the organizations position regarding the term:

A policy adopted by physicians, residents, and medical students at the American Medical Associations (AMA) Special Meeting of its House of Delegates (HOD) opposes excited delirium as a medical diagnosis and warns against the use of certain pharmacological interventions solely for a law enforcement purpose without a legitimate medical reason.

The new policy addresses reports that show a pattern of using the term excited delirium and pharmacological interventions such as ketamine as justification for excessive police force, disproportionately cited in cases where Black men die in law enforcement custody. Specifically, the policy:

As part of its statement, the AMA recommended that all law enforcement and EMS responders be trained in de-escalation techniques and the appropriate use of pharmacological intervention for agitated individuals in the out-of-hospital setting. In the AMAs view, subjects who are clearly experiencing mental health emergencies should be attended to by medical and behavioral health professionals, not law enforcement.

In March 2023, the National Association of Medical Examiners (NAME) made its position clear on the topic. In astatementon its website, the organization said that [a]lthough the terms Excited Delirium or Excited Delirium Syndrome have been used by forensic pathologists as a cause of death in the past, these terms are not endorsed by NAME or recognized in renewed classifications of the WHO, ICD-10, and DSM-V.

The next month, the American College of Emergency Physicians (ACEP)reversed its positionon the term excited delirium to bring it in line with the APA and the AMA, disavowing the use of the term in clinical settings. ACEP continues to use the terms hyperactive delirium and hyperactive delirium syndrome with severe agitation.

The American College of Medical Toxicology (ACMT)made a statementin May 2023 recommending that its members abandon the term excited delirium as a diagnosis and a cause of death. Notably, the ACMT recognized the continuing need for a term to describe patients with altered mental status who are aggressive or have vital signs suggestive of excessive adrenergic activity. The organization advocated for the term hyperactive delirium with agitation, pointing out that de-escalation techniques (sometimes involving sedatives) would still be necessary for some subjects. Physical restraints, which were so often associated with deaths in excited delirium patients, should be minimized and discontinued as early as possible.

In October 2023, ACEP withdrew approval of its 2009 white paper, Report on Excited Delirium Syndrome, recommending that the term 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. This is especially notable because ACEPs 2009 paper was one of the most-cited sources to justify cases involving the condition. According to anAP reportpublished by theJournal of Emergency Medical Services, the white paper shaped police training and still figures in police custody death cases, many involving Black men who died after being restrained by police.

The same month, the state of Californiapassed a lawbanning the use of excited delirium by coroners, medical examiners and law enforcement in any reports. The law, known asAB 360, specifies that excited delirium is not recognized as a valid medical condition or cause of death in the state and evidence that a person experienced excited delirium is inadmissible in any civil action. The law also made a point of banning alternative terms such as hyperactive delirium, agitated delirium and exhaustive mania.

In the wake of the George Floyd case, many states and the District of Columbia enactedreforms to police proceduresand oversight. Quite a few banned the use of chokeholds and neck restraints by law enforcement. Moving away from the use of the term excited delirium is an extension of thesereform efforts. As noted, Lexipol removed the term from our policy guidance in 2022.

There is no consensus on an alternative term to use for the now-discontinued terms. Part of this is due to the dubious nature of the syndrome itself. Excited delirium was never recognized in the medical literature as an actual mental disorder, and anyway, first responders arent trained or qualified to diagnose and treat mental disorders.

Law enforcement and EMS personnel will continue to be called upon to assist with people exhibiting extremely violent, confused behavior. Because of this, its recommended that first responders avoid any medical-sounding jargon and focus on actual observed behavior. In radio traffic,in reportsand in public statements, its best to describe the behavior exhibited by the subject. A few examples:

Focusing on observed behavior rather than quasi psychological terms will help protect both the individuals needing assistance and the law enforcement officers responding to the situation, while also improving public safety reporting and practices.

For more information about this topic, including recommendations on techniques to help protect the safety of both subjects and law enforcement officers, please see Lexipols article, Understanding Excited Delirium: 4 Takeaways for Law Enforcement Officers.

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Excited delirium: Understanding the evolution away from a ... - Police News