Excited delirium (ExDS), also known as agitated delirium (AgDS), is a widely rejected pseudoscientific diagnosis characterized as a potentially fatal state of extreme agitation and delirium. It has disproportionately been diagnosed postmortem in black men who were physically restrained by law enforcement personnel at the time of death. Mainstream medicine does not recognise the label as a diagnosis. It is not listed in the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases, and is not recognized by the World Health Organization, the American Psychiatric Association, the American Medical Association, the American Academy of Emergency Medicine, or the National Association of Medical Examiners.
The American College of Emergency Physicians, which was an outlier in supporting the diagnosis, changed its position in 2023, stating:
A 2017 investigative report by Reuters found that excited delirium had been listed as a factor in autopsy reports, court records or other sources in at least 276 deaths that followed taser use since 2000. The Taser manufacturing firm Axon published numerous medical studies promoting the diagnosis along with their product.
There have been concerns raised over the use by law enforcement and emergency medical personnel partners to inject sedative drugs, a practice nicknamed "policing by needle", citing claims of excited delirium. The drugs ketamine or midazolam (a benzodiazepine) and haloperidol (an antipsychotic) injected into a muscle have sometimes been used to sedate a person at the discretion of paramedics and sometimes at direct police request. Ketamine can cause respiratory arrest, and in many cases there is no evidence of a medical condition that would justify its use. The term excited delirium is sometimes used interchangeably with acute behavioural disturbance, a symptom of a number of conditions which is also responded to with involuntary injection with benzodiazepines, antipsychotics, or ketamine.
A 2020 investigation by the United Kingdom Forensic Science Regulator found that the diagnosis should not have been used since it "has been applied in some cases where other important pathological mechanisms, such as positional asphyxia and trauma may have been more appropriate". In the U.S., neurologists writing for the Brookings Institution called it "a misappropriation of medical terminology, used by law enforcement to legitimize police brutality and to retroactively explain certain deaths occurring in police custody". The American Psychiatric Association's position is that the term "is too non-specific to meaningfully describe and convey information about a person." The Royal College of Psychiatrists has deprecated use of excited delirium, recommending non-diagnostic descriptions for highly agitated states such as acute behavioral disturbance.Royal College of Psychiatrists (2022) College Position Statement PS02/22: ‘Acute behavioural disturbance’ and ‘excited delirium
History Throughout the 19th and early-20th century, "excited delirium" was used to describe an emotional and agitated state related to drug overdose and withdrawal or poisonings, similar to catatonia or Bell's mania, with some believing them to be the same condition.
In 1985, an article titled "Cocaine-induced psychosis and sudden death in recreational cocaine users", co-authored by Dade County deputy chief medical examiner Charles Victor Wetli was published in the Journal of Forensic Sciences. The article describes a state of "excited delirium" in cocaine users leading to respiratory collapse and death, despite the people having blood concentrations of cocaine ten times lower than those seen in fatal overdoses. In five of the seven cases presented in the article, the deaths occurred while in police custody. In 1988, Wetli claimed that a series of nineteen women, all Black prostitutes, had died of excited delirium due to "sexual excitement" while under the influence of cocaine. Police later announced they had found a serial killer, Charles Henry Williams, responsible for those deaths.
By the 1990s, the term "excited delirium" (ExDS) began to be used as a diagnosis to explain deaths in police custody especially during or after restraint, particularly in Florida. Despite the increasing usage of "excited delirium" in the 1990s by some medical examiners and police, mainstream medical associations refused to recognize the legitimacy of the purported syndrome, and it was never listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the early 2000s, medical commentators noted that excited delirium was used disproportionately against African Americans, and alleged that police often used it to cover up deaths resulting from police brutality while in custody.
Rejection by experts Excited delirium is not recognized by the World Health Organization, the American Psychiatric Association, the American Medical Association, and not listed as a medical condition in the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases. Dr. Michael Baden, a specialist in investigating deaths in custody, describes excited delirium as "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". In June 2021, the Royal College of Psychiatrists in the UK released a statement that they do "not support the use of such terminology [as ExDS or AgDS], which has no empirical evidential basis" and said "the use of these terms is, in effect, racial discrimination".
A 2020 scientific literature review looked at reported cases of excited delirium and agitated delirium. The authors noted that most published current information has indicated that excited delirium-related deaths are due to an occult pathophysiologic process. A database of cases was created which included the use of force, drug intoxication, mental illness, demographics, and survival outcome. A review of cases revealed there was no evidence to support ExDS as a cause of death in the absence of restraint. The authors found that when death occurred in an aggressively restrained individual that fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered the more likely cause of the death.
Position of the American College of Emergency Physicians Prior to 2009, excited delirium was only recognized by medical examiners, not physicians. However, in 2009, a 19-person task force from American College of Emergency Physicians (ACEP) wrote a white paper suggesting that excited delirium should be considered as a valid syndrome, which physicians can use for diagnoses. This suggestion was adopted by the ACEP later in 2009.
In 2017, investigative reporters from Reuters reported that three of the 19 members of the 2009 task force were paid consultants for Axon, the manufacturer of Tasers. Axon frequently blames excited delirium for stun-gun-related deaths.
In 2020, the American Psychiatric Association expressed concern about the ACEP's adoption of excited delirium as a genuine syndrome, due to factors such as disproportionate application to African-Americans:
In 2021, the ACEP created a new task force to reevaluate the excited delirium syndrome. As a result, in 2023 the ACEP withdrew the 2009 white paper, which defined the syndrome, and instead endorsed a new syndrome "hyperactive delirium syndrome with severe agitation".Statement from the ACEP excerpt: "The American College of Emergency Physicians (ACEP) recognizes the existence of hyperactive delirium syndrome with severe agitation, a potentially life threatening clinical condition characterized by a combination of vital sign abnormalities (e.g., elevated temperature and blood pressure), pronounced agitation, altered mental status, and metabolic derangements.... ACEP does not recognize the use of the term “excited delirium” and its use in clinical settings." In a statement, the ACEP said it had "withdrawn its approval of this [the 2009] paper" and that "[t]he term excited delirium 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".
The 2021 ACEP report was criticized by some physicians for failing to sufficiently consider racial bias, similar to the 2009 report:
Mainstream medical organizations continued to withhold recognition of either the old syndrome or new syndrome, due to the absence of scientific rigor or evidence.
In 2023, the state of California became the first in the United States to ban the use of excited delirium as a cause of death.
Controversy Association with racism
In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites, and the American Psychiatric Association also notes that "the term excited delirium is disproportionately applied to Black men in police custody". 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."
Several academic commentators have noted that medical personnel and law enforcement personnel apply diagnoses of excited delirium in a manner which disproportionately disadvantages African Americans. Excited delirium has also been used to diagnose Indigenous people after violent police encounters. In 1999, in Victoria British Columbia, Canada, Anthany Dawson, a member of the Musgamagw Tsawataineuk Nation, was beaten and punched repeatedly by the police before dying in an ambulance. Initially, police statements relayed to the public that overdose was his cause of death, though there was no evidence of drug use at the time of the statements’ release. Later, toxicology reports only found a small amount of marijuana from the previous evening before his death. In the media, Dawson was portrayed as having been mentally ill, but he had no medical history of mental illness. Then, he was believed to have a genetic condition that predisposed him to die of excited delirium which was the documented cause of his death. Dawson's mother, however, maintains that "police force and racism" was the sole cause of her son’s death. By presenting these unfounded individual causes for Dawson’s death, police violence cannot be named as the causal factor in his life ending.
In addition, commentators have alleged that fallacious diagnoses of excited delirium have been used to cover-up instances of police brutality. Excited delirium’s diagnosis serves to cover the racial injustice of police brutality and structural racism, pinning the blame on the victim. By painting the victims in police reports as menacing, unpredictable, and uncontrollable under the pretence of being mentally ill, or under influence of substances, police aggression is not only excused, it is justified. Rather than enacting empathy and compassion for people in vulnerable situations, the police create a dehumanizing narrative wherein the victims’ death is inevitable, where their life reaches a prescribed end. Police procedures and behaviours, their tendency to escalate force and gross neglect goes unexamined and unquestioned. Ultimately, it removes moral culpability and accountability from the police and leaves the victims’ families and communities without justice nor a proper account of their loved ones’ death.
Excited delirium has been described as fundamentally racist by many commentators in the media, including Jon Ronson's BBC podcast Things Fell Apart in 2024. The episode, titled "The Most Mysterious Deaths", describes Wetli's initial coining of the phrase "excited delirium", as well as the later debunking of the phenomenon, and its connection to the murder of George Floyd.