What Is ‘Excited Delirium’ and Why Is It Controversial?

The public most often sees the term invoked in news stories about cases involving deaths in police custody, like George Floyd's.

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Image via Bethania Palma / Snopes

As former Minneapolis police officer Derek Chauvin drove his knee into the neck of a prone, dying George Floyd in May 2020, another Minneapolis cop, Thomas Lane, suggested they roll Floyd onto his side. Why?

“I just worry about the excited delirium, or whatever,” Lane stated.

The phrase “excited delirium” refers to a controversial medical diagnosis that some say presents a real, life-threatening danger to patients and emergency responders, while prominent critics question the medical validity of the condition. Critics also charge that excited delirium is entwined with law enforcement, and that its use has racist elements.

The latter critique was crystalized by Mari Newman, the attorney representing the family of Elijah McClain, a 23-year-old Black resident of Aurora, Colorado, who died in police custody in 2019. McClain was dosed in the field with ketamine, a powerful sedative used to treat excited delirium in the field.

“The thing about it is that it is disproportionately used or articulated in the context of law enforcement interactions with Black men,” Newman told Snopes in a phone interview. “They’re trained to use buzzwords to invoke the specter of excited delirium so they can later justify using excessive force.”

So what is excited delirium? It depends on who you ask.

The public most often sees excited delirium invoked in news stories about cases involving deaths in police custody, like Floyd and McClain. It’s been broadly described as having features like agitation, aggression, confusion, pain insensitivity, superhuman strength, being hot to the touch, sweating, being inappropriately dressed or not dressed, and rapid breathing. In some cases the symptoms can be associated with illicit drug use.

The working theory from some medical experts is that people experiencing excited delirium essentially damage their hearts with huge surges of adrenaline, high body temperature and a release of a large amount of lactic acid into their system, all of which can lead to death, a spokesman for the American College of Emergency Physicians (ACEP), a professional organization representing emergency room doctors, told us in an email.

The George Floyd Case

Floyd, a 46-year-old Black man, died in custody on May 25, 2020, and his final, excruciating nine minutes, which was captured on camera by a bystander and posted to social media, set off nationwide civil rights demonstrations over the spring and summer of 2020. Massive numbers of people attended protests, even in the face of COVID-19 pandemic dangers.

Chauvin has been charged with murder and manslaughter, and is, as of this writing, going on trial. The other three officers, Lane, Tou Thao, and Alexander Kueng, who were on scene as Floyd lay pinned by Chauvin and handcuffed, have been charged with aiding and abetting murder and manslaughter. They are expected to go to trial on these charges in August 2021.

The use of the phrase by one of Chauvin’s fellow officers led to speculation that excited delirium may be used to defend him in court. Excited delirium has often been raised as a defense for the use of physical force by police and the use of police hardware such as Tasers in cases of in-custody deaths.

Why Excited Delirium Is Controversial

Excited delirium is controversial among medical professionals. It is recognized by ACEP. It is not recognized by the American Medical Association or the World Health Organization.

Most importantly, perhaps, excited delirium isn’t recognized by the American Psychiatric Association. And while delirium is a well-defined psychiatric disorder, excited delirium isn’t listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the reference manual that medical professionals consult for psychiatric disorders.

“Excited delirium does not map onto any clearly recognized medical syndrome,” Dr. Paul S. Appelbaum, director of the Center for Research on Ethical, Legal and Social Implications of Psychiatric, Neurologic & Behavioral Genetics in the Department of Psychiatry at Columbia University’s College of Physicians and Surgeons, told Snopes in a phone interview.

Appelbaum, who is also past president of the American Psychiatric Association, noted that many of the features attributed to excited delirium don’t fit into the DSM definition of delirium. Instead, Appelbaum called it a “wastebasket term” often used by police and EMTs for people who are difficult to control, which could be because of a wide range of reasons. But in the aftermath of such cases, efforts are rarely made to determine whether the person was suffering from actual delirium, Appelbaum told us.

“Excited delirium is a term that covers up more than it reveals,” Appelbaum said by phone. “It pretends to be an explanation, but it just takes the place of a real explanation” for what a patient may be experiencing, which may include underlying medical conditions, substances in their systems, fear of the encounter with police, or any combination of factors.

History of Excited Delirium

Many experts trace the condition now known as excited delirium to 1849, when a description of what was then called “Bell’s mania” was first employed by Dr. Luther Bell at the MacLean Asylum for the Insane in Massachusetts. It “manifested as acute exhaustive mania and delirium that was associated with a 75% fatality rate,” according to Roger Byard, the George Richard Marks Chair of Pathology at the University of Adelaide in Australia, in an August 2017 article for the journal Forensic Science, Medicine and Pathology.

Byard, who is editor-in-chief of the journal and also serves as a senior specialist forensic pathologist at Forensic Science SA in Adelaide, Australia, stated that the number of cases fell in the 1950s with the introduction of antipsychotic drugs, but rose again in the 1980s with the growing use of street drugs like cocaine, PCP, LSD, and methamphetamines.

Both the past and modern iterations of excited delirium as a psychiatric syndrome are controversial. In a July 2020 op-ed for The Washington Post, neurologists Méabh O’Hare, Joshua Budhu, and Altaf Saadi stated that although they couldn’t retroactively diagnose patients from two centuries ago, they believed deaths from “Bell’s mania” likely resulted instead from “forms of infectious or autoimmune encephalitis.”

An October 2019 investigation by Florida Today noted that the 1980s cases that brought the excited delirium diagnosis into the modern era involved the deaths of a series of Black women, many of them sex workers. The forensic pathologist Charles Wetli at the time attributed their deaths to the stimulant effects of cocaine and sex. But when the cases were reexamined, investigators discovered that the women were the victims of a serial killer.

Law Enforcement Endorsement

Many law enforcement groups maintain that excited delirium, sometimes referred to as “ExDS,” is a real phenomenon that they encounter in the field. In an FBI bulletin to law enforcement agencies, three emergency physicians said that “excited delirium is becoming increasingly recognized as an important medical emergency encountered in the prehospital environment.”

In 2009, the American College of Emergency Physicians (ACEP) published a white paper describing one feature of excited delirium in a prehospital setting as “police noncompliance.”

Both the FBI bulletin and the 2009 ACEP paper communicate a sense of urgency for the recognition of excited delirium by police officers in the field, stating that the condition can be deadly for both first responders, due to potentially violent behavior by the patient, and to the patient, due to the potential for imminent death from excited delirium. The ACEP paper describes that danger and also notes that officers who encounter patients experiencing the condition are placed in a particularly bad situation — a volatile situation in the field combined with inevitable public scrutiny:

Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS subject, any LEO interaction with a person in this situation risks significant injury or death to either the LEO or the ExDS subject who has a potentially lethal medical syndrome. This already challenging situation has the potential for intense public scrutiny coupled with the expectation of a perfect outcome. Anything less creates a situation of potential public outrage. Unfortunately, this dangerous medical situation makes perfect outcomes difficult in many circumstances.

But ACEP’s inclusion of the refusal to comply with officers’ orders in the list of excited delirium features is evidence of the condition’s “entanglement with law enforcement,” Drs. O’Hare, Budhu, and Saadi argued in the Washington Post op-ed. They also noted there is a racial facet to law enforcement’s reliance on diagnoses of excited delirium:

The syndrome is disproportionately diagnosed among young black men, highlighting the racist undertones of the reported clinical symptoms: having “superhuman strength” and being “impervious to pain.” It winds up being a convenient scapegoat cause of death after a violent confrontation. Or it becomes a justification for police aggression that may be unwarranted.

“Part of the controversy about the use of this term is exactly that it is allegedly being used to cover up police misconduct or causes of death that are related to, for example, the use of Tasers,” Appelbaum told us.

A 2017 investigation by Reuters reported that the manufacturers of Taser stun guns used by police often insert themselves in in-custody death cases in which Tasers were used, defending the safety of its products by pointing to other factors “including a condition at the center of a medical debate: ‘excited delirium.'”

Appelbaum said ACEP’s role in the controversy outlines the conflict in the medical community over the term — namely because ACEP represents a group of doctors who don’t specialize in psychiatry.

“Most other medical specialties would refer to the DSM when it comes to the diagnosis for psychiatric syndromes,” Appelbaum told us, calling it “unusual” for physicians to christen a syndrome that lies outside their field. And, he added, even those who maintain that excited delirium is a real medical condition haven’t given a “clear operational definition of what it actually is.”

When we reached out to ACEP for comment, a spokesperson told us:

In 2009, the American College of Emergency Physicians (ACEP) had a task force which produced an information paper that acknowledged excited delirium as a real condition, and discussed its impact on patients’ health, including mortality rate. The 2009 information paper was not officially endorsed by ACEP and the body of literature around excited delirium and the use of Ketamine has grown significantly since its publication. This year, ACEP formed a new task force to deepen the understanding around the best treatment for excited delirium.

This group of emergency physicians, EMS physicians, pharmacists, toxicologists, anesthesiologists, nurses, and patient safety experts will be evaluating literature and research on excited delirium since 2009 to make recommendations for the use of ketamine in prehospital settings.”

Controversy Over Ketamine Treatment

The recommended treatment, according to ACEP, for excited delirium is ketamine, a powerful sedative often used for pain relief and to induce anesthesia.

But the use of ketamine to treat people in the field is also highly controversial, as was highlighted by its role in the death of McClain.

An independent panel that investigated the circumstances of McClain’s death reported that paramedics overestimated McClain’s weight and gave him a dose consistent with someone significantly heavier than McClain’s slight, 140-pound frame.

American Society of Anesthesiologists President Dr. Mary Dale Peterson said in a phone interview with Snopes that ketamine has a good safety profile in clinical settings, where the situation is controlled and patients can be continuously monitored.

But increasingly, ketamine is being given in the field for excited delirium, and field settings can be chaotic, poorly lit, and for any number of reasons, it may be difficult to closely monitor a patient’s response to the drug.

A July 2020 analysis by Colorado public radio news station KUNC found that the state’s emergency medical responders administered ketamine in the field 902 times in the span of 2 1/2 years. Of those cases, 17% of patients experienced complications associated with the administration of the drug.

KUNC quoted a June 2020 letter signed by emergency room doctors from across the U.S. supporting the field use of ketamine, which said the drug “safeguard the patients, while also reducing the risk of violence directed against EMS and public safety workers.”

But Peterson said that the rate of complication tells another story.

“The complication rate is clearly too high,” Peterson told us. “That should be a red flag that the protocol should be reviewed — whether ketamine is given at all, in what doses, how the patient is monitored, et cetera.”

Opening arguments in Chauvin’s murder trial are set to begin on March 29, 2021.