Recognising Excited Delirium Is Crucial For Police Reform
Nothing is gained by denying the syndrome exists
On the 23rd of March this year Daniel Prude, a black man, was restrained by New York Police after acting erratically whilst visiting his brother. Whilst being taken into custody, Prude was cuffed and a spit hood placed over his head.
Prude began to panic as a result of the spit hood and repeatedly tried to stand up, only to be pushed down by officers. At one point, Officer Mark Vaughn used his body weight to press Prude’s head into the pavement whilst Officer Troy Talladay applied his knee to Prude's back.
The measures were designed to make Prude comply with restraint. After applying force for three minutes, the officers discovered that Prude had vomited and had stopped breathing. Prude was declared brain dead at Strong Memorial Hospital and was taken off life support a week later.
A subsequent autopsy ruled Prude’s death a homicide resulting from "complications of asphyxia in the setting of physical restraint." However, it also noted contributing factors including ‘excited delirium’ and intoxication with PCP.
Prude’s death has led to a series of protests in New York against police brutality. However, some commentators have seized on Prude’s drug use and - in particular - the diagnosis of excited delirium as a crucial factor in his death.
The controversial diagnosis of ‘excited delirium’ has be cited in dozens of cases of deaths in police custody. It was suspected as a relevant factor in the death of George Floyd and has been used to justify the ketamine-related death of Elijah McClain. The diagnosis has also been noted as a cause of death in police restraint cases in Australia.
Eric Balabun, senior staff counsel for the ACLU's National Prison Project has called excited delirium ‘blaming the victim’ and noted it as a factor in avoiding police accountability. This has led many progressive commentators to dismiss excited delirium as ‘pseudoscience’ or a diagnosis designed to cover up police brutality.
This framing is incredibly unhelpful.
It is crucial we recognise excited delirium as a key factor in police and custody-related deaths. Only through acknowledging particular vulnerabilities of offenders can we improve police responses.
What Is Excited Delirium?
Excited delirium, also known as agitated delirium, is a syndrome categorised by agitation, sweating, high body temperature and disturbances in attention, consciousness and cognition.
Patients with excited delirium are often described as violent and display unexpected strength when attempts are made to restrain them.
A syndrome is a constellation of symptoms which may indicate more than one underlying cause. In this case, excited delirium syndrome is characterised by an extreme level of stress-related neurotransmitters including dopamine, epinephrine (adrenaline) and norepinephrine (noradrenaline).
Only in a minority of cases is excited delirium fatal. The mortality rate is noted as being between 8-10% of cases, usually the result of cardiac arrest.
Excited delirium typically occurs in men in their 30s after cocaine or methamphetamine use. These drugs are stimulants and increase the release and/or prevent the reuptake of key neurotransmitters such as dopamine.
Agitation is a common side effect of stimulant abuse, but is highly influenced by external factors such as mindset and setting. As such, it’s too simplistic to call excited delirium a direct side effect of stimulant use.
More accurate is to describe the syndrome as a complex reaction to drug effects combined with a hostile or stressful environmental stimuli along with other underlying risk factors.
The diagnosis has been noted as similar to an earlier documented psychiatric condition known as Bell’s mania.
It’s commonly noted by critics that neither American Psychiatric Association nor the World Health Organisation recognises excited delirium syndrome as a specific clinical entity.
However, this is largely due to inconsistencies in the literature in developing diagnostic criteria, rather than excited delirium existing as a ‘pseudoscientific’ diagnosis.
One of the major diagnostic issues is that the umbrella term of ‘excited delirium syndrome’ seems to encompass a number of ICD-10 codes including delirium (induced by drug or not), agitation (psychomotor) and abnormal/psychomotor/manic excitement.
The American College of Emergency Physicians has recognised excited delirium as a valid diagnosis since 2009, as have the National Association of Medical Examiners. The consensus of the American College of Emergency Physicians Task Force in 2012 was that “Excited Delirium Syndrome is a real syndrome, with uncertain, likely multiple, etiologies”.
Although focus is often on deaths by excited delirium within a law enforcement context, syndrome-related deaths are more likely to occur in emergency rooms or psychiatric settings.
Despite the complexity of excited delirium syndrome, most recent systematic reviews on the topic have concluded that this is a real clinical entity that can result in death.
How Should It Alter Policing?
The existence of excited delirium, rather than acting as an excuse for the status quo, should be highlighted as an argument in favour of police reform.
Police are often called into situations where a person is observed acting erratically or aggressively. The primary approach taken by law enforcement in these situations is to maintaining social order in response to seemingly wilful anti-social behaviour.
Recognising excited delirium makes it clear that such ‘wilful’ disturbances of the peace may actually indicate a potentially life-threatening medical condition.
Several reviews have noted that police responses to situations of health crisis are poor. Police, even when trained, tend to use more aggressive and coercive measures in response to people who are unwell than other professionals.
The potential for escalation is especially high as individuals experiencing excited delirium aren’t likely to comply with police orders. One Canadian study found that in cases where subjects had suspected excited delirium a struggle between subject and officer occurred in 89% of cases.
Although evidence is emerging, heavy-handed police responses including restraint likely plays a role in increasing the risk of cardiac related deaths in cases of excited delirium.
Moreover, the existence of excited delirium may indicate that standard clinical guidelines related to violence or extreme agitation, including sedation and restraint, could be counterproductive.
All of this provides a strong argument in favour of alternatives to standard policing in cases of erratic or aggressive behaviour.
One solution could be the expansion of Crises Resolution Teams to decrease rates of restraint, with police acting in an assisting role rather than as primary responders to erratic behaviour.
Whilst police abolition remains a radical (and in my opinion, unworkable) model in response to failures of traditional policing, there is scope to re-think the role of traditional law enforcement.
Overall, by recognising excited delirium we can highlight the failures of punitive “law and order” policing to provide tailored and evidence-based responses to anti-social behaviour.