Excited delirium: Understanding the evolution away from a controversial term

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:

• The American Medical Association
• The American Psychiatric Association
• The American Academy of Emergency Medicine
• The National Association of Medical Examiners
• The American College of Medical Toxicology
• The American College of Emergency Physicians

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

Old understanding

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

• A disturbed state of mind, including anger, violent behavior, fear and panic
• Elevated body temperature (hyperthermia), usually coupled with excessive sweating
• A sudden pause in the behavior, during which subjects stop struggling
• Sudden respiratory arrest, often leading to death

This condition has variously been labeled “Bell’s 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 Fishbain dubbed the condition “excited 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”).

A report on the topic in the Western Journal of Emergency Medicine noted 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 in Force Science stated the symptoms labeled as “excited delirium” can be caused by a number of very different medical conditions:

• Hyperthermia: A person with an internal body temperature of 102 or higher may exhibit symptoms similar to alcohol or drug intoxication.
• Diabetes: A diabetic person with low blood sugar may exhibit sudden changes of mood, confusion and bursts of anger — plus an elevated heart rate, excessive sweating and even seizures.
• Head injury: Someone with traumatic brain damage may have no visible injuries but still show signs of mania, disorientation, psychosis and other aggressive conduct. In addition, these symptoms may manifest months or even years after the head injury occurred.
• Delirium tremens: Someone with “the DTs,” or alcohol withdrawal, can manifest symptoms similar to those associated with “excited delirium,” including mood swings, anxiety, body tremors, excessive sweating, paranoid thoughts and hallucinations.
• Thyroid storm: More common in women than men, the rare condition of thyroid storm can look very similar to “excited delirium” in a subject.

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.

Problematic application

According to a 2022 report prepared 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 into in-custody deaths in Texas from 2005 through 2017 showed that “excited delirium” was blamed for 17% of the 289 cases. A similar study in Florida demonstrated 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, a 2021 article in the Virginia Law Review revealed 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.

The turning point

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.

APA Position Statement on “Excited Delirium”

In the wake of Floyd’s 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, coroner’s reports and news stories. In December 2020, the APA made the following official statement on 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 the DSM-5, the most current update to the Diagnostic 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 with ketamine, 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.”

AMA Position Statement on “Excited Delirium”

Half a year later, in June 2021, the American Medical Association (AMA) put out its own press release stating the organization’s position regarding the term:

A policy adopted by physicians, residents, and medical students at the American Medical Association’s (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:

• Confirms the AMA’s stance that current evidence does not support “excited delirium” as an official diagnosis, and opposes its use until a clear set of diagnostic criteria has been established
• Denounces “excited delirium” as a sole justification for law enforcement use of excessive force
• Underscores the importance of emergency physician-led oversight of medical emergencies in the field
• Opposes the use of sedative/hypnotic and dissociative drugs — including ketamine — as an intervention for an agitated individual in a law enforcement setting, without a legitimate medical reason
• Recognizes the risk that sedative/hypnotic and dissociative drugs have in relation to an individual’s age, underlying medical conditions, and potential drug interactions when used outside of a hospital setting by a non-physician

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 AMA’s view, subjects who are clearly experiencing mental health emergencies should be attended to by medical and behavioral health professionals, not law enforcement.

Other groups reverse positions

In March 2023, the National Association of Medical Examiners (NAME) made its position clear on the topic. In a statement on 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 position on 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 statement in 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 ACEP’s 2009 paper was one of the most-cited sources to justify cases involving the condition. According to an AP report published by the Journal 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 California passed a law banning the use of “excited delirium” by coroners, medical examiners and law enforcement in any reports. The law, known as AB 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.”

Describe, don’t diagnose

In the wake of the George Floyd case, many states and the District of Columbia enacted reforms to police procedures and 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 these reform 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 aren’t 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, it’s recommended that first responders avoid any medical-sounding jargon and focus on actual observed behavior. In radio traffic, in reports and in public statements, it’s best to describe the behavior exhibited by the subject. A few examples:

• “Subject had stripped to his underwear and was shouting at and attempting to punch anyone who came near him.”
• “The subject was aggressive and combative, kicking and spitting and cursing as officers tried to talk to him in order to calm him down.”
• “The subject was extremely agitated, breathing rapidly and sweating profusely, and was observed by officers trying to smash the windows of cars parked on the street with his bare fists.”

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 Lexipol’s article, “Understanding Excited Delirium: 4 Takeaways.”