Excited Delirium

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2021-01-18

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Excited delirium (EXD), also known as agitated delirium, is a controversial syndrome described as a combination of psychomotor agitation, delirium, and sweating. It may include attempts at violence, unexpected strength, and very high body temperature. Complications may include rhabdomyolysis or high blood potassium.

Excited delirium is not recognized by the World Health Organization, the American Psychiatric Association, or the American Medical Association, and therefore not listed as a medical condition in the Diagnostic and Statistical Manual of Mental Disorders.

The UK Independent Advisory Panel on Deaths in Custody (IAP) suggests that the syndrome should be termed “Sudden death in restraint syndrome” in order to enhance clarity. Examples of deaths due to the condition are found primarily in restraint or attempted restraint situations, while medical preconditions and symptoms attributed to the syndrome are far more varied.

Definitions and symptoms

EXD has been accepted by the American College of Emergency Physicians, who argue in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9. A November 2012 The Journal of Emergency Medicine literature review says that the American College of Emergency Physicians Task Force reached consensus, based on "available evidence, that Excited Delirium Syndrome (EDS) is a "real syndrome with uncertain, likely multiple, etiologies."

According to one 2020 publication, "excited delirium syndrome" is a "clinical diagnosis" with symptoms including delirium, psychomotor agitation, and hyperadrenergic autonomic dysfunction.

The diagnosis was not in the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 or the 1992 International Classification of Diseases.

Treatment and prognosis

Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person. Rapid cooling may be required in those with high body temperature. Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful. One of the benefits of ketamine is its rapid onset of action. The risk of death among those affected is less than 10%. If death occurs it is typically sudden and cardiac in nature. Concern has been raised by some medical professionals about the increasing usage of a claim of excited delirium to justify tranquilizing persons during arrest, with requests for tranquilization often being made by law enforcement rather than medical professionals. Ketamine is the most commonly used drug in these cases.

Epidemiology

How frequently cases occur is unknown. Males account for more documented diagnoses than females. Deaths associated with the condition are typically males with an average age of 36. Often law enforcement has used tasers or physical measures in these cases, and death most frequently occurs after the person is forcefully restrained.

Signs and symptoms

The signs and symptoms for excited delirium may include:

Severe panic or distress, often exhibiting paranoia
Disorientation
Dissociation
Aggressiveness and combativeness
Fast heart rate
Hallucination
Diaphoresis (profuse sweating)
Incoherent speech or shouting
Unexpected strength (typically while trying to resist restraint)
Hyperthermia (overheating)
Inappropriately clothed e.g. having removed garments

Cause

Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV. Alcohol withdrawal or head trauma may also contribute to the condition. Physical struggle, especially if prolonged, has been shown to greatly exacerbate many of the harmful symptoms such as metabolic acidosis, hyperthermia, catecholamine surge, and tachycardia. A majority of fatal cases involved men in a law enforcement or restraint situation.

People with excited delirium frequently have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine. Other drugs that may contribute to death are antipsychotics.

The cause is often related to long-term drug use or mental illness. Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones. In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition.

Mechanisms

The pathophysiology of excited delirium is unclear, but likely involves multiple factors. These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal abnormal heart rhythms. The underlying mechanism may involve dysfunction of the dopamine system in the brain.

Diagnosis

Key signs of excited delirium are aggression, altered mental status, and diaphoresis/hyperthermia.

Other conditions which can resemble excited delirium are mania, neuroleptic malignant syndrome, hypoglycemia, thyroid storm, and catatonia of the malignant or excited type.

History

In 1849 a similar condition was described by Luther Bell as "Bell's mania". The first use of the term "excited delirium" (EXD) was in a 1985 Journal of Forensic Sciences article, co-authored by coroner, Charles V. Wetli, entitled "Cocaine-induced psychosis and sudden death in recreational cocaine users". The JFS article reported that in "five of the seven" cases they studied, deaths occurred while in police custody.

Controversy related to policing techniques

The condition is not recognized by the American Psychiatric Association, American Medical Association or the World Health Organization. Critics of excited delirium have stated that the condition is primarily attributed to deaths while in the custody of law enforcement and is disproportionately applied to black and Hispanic victims. Eric Balaban of the American Civil Liberties Union argued in 2007 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."

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. In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.

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 electric weapon. He called excited delirium a "dubious disorder" used by Taser International in its training of police. In a 2008 report, the Royal Canadian Mounted Police 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.

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.