Excited delirium: valid clinical diagnosis or medicalized racism? Organized medicine needs to take a stand

The “diagnosis” of excited delirium, a term often used to justify and defend police brutality, disproportionately against Black people, has circulated in the medical canon for more than 25 years. It is time — past time, actually — for organized medicine to denounce its diagnostic validity and its use as a shield to justify excessive police force.

It reemerged most recently on May 25, 2020, when Minneapolis police officer Derek Chauvin killed George Floyd, an unarmed Black man, by kneeling on his neck for more than nine minutes. During that time, fellow officer Thomas Lane was heard to say, “I am worried about excited delirium or whatever.”

While Floyd’s death was ruled a homicide, the autopsy report cited coronary artery disease, hypertension, fentanyl intoxication, and recent methamphetamine use as contributing factors, raising the specter that excited delirium may be used in the officers’ defense trials. Chauvin’s defense attorney has already signaled in his opening statement that excited delirium will come up in his trial, which is now underway.

Delirium is a well-defined clinical entity, described in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders as an acute change in attention, awareness, and cognition caused by an underlying medical condition, substance, or exposure to a toxin or withdrawal from one. It is not, however, associated with sudden death.

Excited delirium, however, is not listed in the manual.

The term was first used in 1985 by forensic pathologist Charles Wetli to explain the cause of a series of seven deaths among people who used cocaine, all of whom were forcibly restrained and five of whom died in police custody. (It’s important to note that while six of the seven people in Wetli’s initial case series were white, a subsequent review of all cases of death from excited delirium between 1969 and 1990 in Dade County, Fla., showed that Black men were more than three times as likely to have their cause of death labeled as excited delirium than their white counterparts. More contemporary studies continue to demonstrate the disproportionate impact on Black people.)

Since Wetli’s report, there has been weak support for the concept of excited delirium. A systematic review of studies showed that it had not been defined as a specific clinical entity and there was no proven biological pathway linking it to sudden death.

Use of cocaine and other stimulants is often blamed as the cause of sudden death in excited delirium cases through a variety of unproven physiologic mechanisms. But the plausibility of these theories is in doubt: Despite similar rates of cocaine use across race and ethnicity in the U.S, studies show that younger Black men who use cocaine and who are in police custody are at highest risk for death from excited delirium.

Despite limited medical evidence, police departments across the country began training their officers to identify excited delirium as a potentially deadly medical condition. The diagnosis quickly emerged as a defense for police in cases of people who died in police custody and who were later found to have alcohol and other drugs present upon autopsy. Several high-profile cases in which excited delirium has been invoked to defend police officers in the deaths of Black people in custody include Natasha McKenna, Manuel Ellis, Elijah McClain, Gregory Lloyd Edwards, and Daniel Prude; countless others have never reached the public’s attention. A recent review found that excited delirium was documented in 3% of police interventions and 10% of deaths in police custody.

The most extensive review of all cases of excited delirium to date, published in 2020, found that the “syndrome” was most often fatal in the presence of aggressive forms of police restraint, including manhandling and hog- or hobble-ties. The authors concluded that “excited delirium is not a unique cause of death in the absence of restraint.” They discounted acute stimulant intoxication as a direct cause of death, given typically sublethal drug levels found on autopsy.

Instead, they concluded that the association between stimulant use and death is likely secondary to the use of aggressive police maneuvers. They argued that excited delirium should be abandoned as a diagnostic construct for use in medicolegal death investigations and that it be replaced with diagnostic terminology that would require medical examiners to document the presence and severity of police restraint used in each case of a death of an agitated, delirious individual.

In 2009, the American College of Emergency Physicians (ACEP) assembled a task force on excited delirium. It reported that, despite unclear pathophysiology and significant overlap with other medical and psychiatric conditions, excited delirium was “a real syndrome.” Despite the task force’s stated intentions to clarify this entity and reduce harm for individuals experiencing severe agitation, an additional decade of research on excited delirium has yet to support its clinical validity or describe how it causes sudden death.

How racism infuses the concept of excited delirium and corrupts its use in the criminal legal context also remains unexamined, underscoring a critical opportunity for the ACEP to revisit its position.

Racist pseudoscience, rooted in our nation’s history of Black enslavement, continues to taint modern medical practice, drug policy, and policing. Racist notions of the “cocaine-crazed negro brain” leading to “resistance to the knock down effects of fatal wounds” circulating among physicians during the passage of the 1914 Harrison Narcotics Act have not retreated into the past. Instead, such ideas have morphed into exaggerated claims that certain drugs cause “super-human strength,” “psychosis,” and “irrationality” in Black bodies (all terms that have been used to describe features of excited delirium). These claims coexist alongside other racist beliefs pervasive in medicine, such as that Black people have thicker skin and feel less pain than white people.

The syndrome of excited delirium does not serve as a diagnostic construct should: a defined set of signs and symptoms used to identify a person in distress and in need of urgent medical or psychiatric help. Instead, it is contributing to greater harm, especially for Black people. When such a flawed diagnostic construct is applied, in the context of ongoing anti-Black racism, it is used to justify greater aggression by police towards Black people and reinforces a blame-the-victim defense of police violence, implying that Black people are culpable for their own deaths, attributable to drug use and their own faulty biology.

Floyd’s case is painfully instructive in the real-world uses and harms of excited delirium, particularly for Black people who use drugs or experience mental illness. The possible existence of the syndrome was raised by an officer on the scene as a concern, which was at best ignored and at worst served to legitimize the continued use of force against Floyd’s “super-human strength.” Indeed as Floyd pleaded that he couldn’t breathe, former Minneapolis police officer Tou Thao declared to the crowd “This is why you don’t do drugs kids.”

It would be shame if excited delirium is used to defend Chauvin and the other officers involved in their criminal trials.

Medical organizations need to formally denounce the diagnostic validity and use of excited delirium to justify excessive police force. Doing this doesn’t deny that people of all races do, in fact, experience severely agitated states that place them at risk for harm to themselves and others. Nor does it assert that first responders should not be trained in de-escalation strategies or how to identify medical and psychiatric illness requiring urgent medical care. Instead, a denunciation would affirm that this so-called syndrome can no longer stand as a medicolegal shield for police brutality that disproportionately affects Black people.

Organized medicine must also go further and support calls for investments in innovative, trauma-informed responses to medical and psychiatric crises in the community that do not involve police. Increased access to substance use treatment and mental health care, tailored to the needs of Black people, is also essential.

If organized medicine is to fulfill its racial justice pledges made in the wake of Floyd’s death to “dismantle racist and discriminatory policies and practices across all of health care,” as the American Medical Association said, it must no longer remain silent on this issue.

Jennifer K. Brody is a primary care physician specializing in HIV and addiction medicine, director of HIV services at the Boston Health Care for the Homeless Program, and an instructor of medicine at Harvard Medical School. Ayana Jordan is an addiction psychiatry physician at Connecticut Mental Health Center, and director of the Medication for Addiction Treatment Consultation Service and assistant professor of psychiatry at Yale School of Medicine. Sarah Wakeman is an addiction medicine physician at Massachusetts General Hospital, medical director of the Massachusetts General Hospital Substance Use Disorder Initiative, and an associate professor of medicine at Harvard Medical School.

Hear Brody and Jordan talk more about “excited delirium” on an episode of the “First Opinion Podcast.”