For decades, law enforcement officers, medical examiners and emergency medical professionals have used the terms 鈥渆xcited delirium鈥� and 鈥渆xcited delirium syndrome鈥� 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 鈥渆xcited delirium鈥� 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 鈥渆xcited delirium鈥� from our policy guidance in 2022. Regardless of your agency鈥檚 policy on the use of this term, it鈥檚 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 鈥淏ell鈥檚 mania,鈥� 鈥渁cute exhaustive mania,鈥� 鈥渓ethal catatonia鈥� and 鈥渁gitated delirium.鈥� In 1985, at the height of the U.S. crack cocaine epidemic, researchers Charles Wetli and David Fishbain 鈥渆xcited delirium,鈥� 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 鈥淓XD鈥� (for 鈥渆xcited delirium鈥�) or 鈥淓xDs鈥� (for 鈥渆xcited delirium syndrome鈥�).
A in the Western Journal of Emergency Medicine noted that 鈥渆xcited delirium鈥� and 鈥渁gitated delirium鈥� described a subject exhibiting 鈥渁gitation, aggression, acute distress and sudden death, often in the pre-hospital care setting.鈥� The report pointed out that about 鈥渢wo thirds of EXD victims die at the scene or during transport by paramedics or police.鈥� 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 stated the symptoms labeled as 鈥渆xcited delirium鈥� 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 鈥� 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 鈥渢he DTs,鈥� or alcohol withdrawal, can manifest symptoms similar to those associated with 鈥渆xcited delirium,鈥� 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 鈥渆xcited delirium鈥� in a subject.
During the 2000s and 2010s, officers may have been taught to recognize and respond to 鈥渆xcited delirium鈥� 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 prepared by Physicians for Human Rights (PHR), multiple studies have suggested that diagnoses of 鈥渆xcited delirium鈥� may have been used to justify excessive use of force by law enforcement. A look into from 2005 through 2017 showed that 鈥渆xcited delirium鈥� was blamed for 17% of the 289 cases. A 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 鈥渢he term 鈥榚xcited delirium鈥� cannot be disentangled from its racist and unscientific origins.鈥� For example, a in the Virginia Law Review revealed that, of 166 in-custody deaths across the country, Black subjects made up over 43% of those with 鈥渆xcited delirium鈥� 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 鈥渆xcited delirium.鈥� 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 鈥渆xcited delirium鈥� later pled guilty to aiding and abetting second-degree manslaughter.
APA Position Statement on 鈥淓xcited Delirium鈥�
In the wake of Floyd鈥檚 death and the subsequent demonstrations and unrest, many organizations 鈥� including the American Psychiatric Association (APA) 鈥� revisited their positioning on the use of 鈥渆xcited delirium鈥� in police reports, coroner鈥檚 reports and news stories. In December 2020, the APA made the following 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 鈥渆xcited delirium鈥� (ExDs) is too non-specific to meaningfully describe and convey information about a person. 鈥淓xcited delirium鈥� should not be used until a clear set of diagnostic criteria are validated.
2. An investigation should be undertaken of cases labelled with 鈥渆xcited delirium鈥� 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 鈥渆xcited delirium鈥� 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 , the most current update to the Diagnostic and Statistical Manual of Mental Disorders, does not list 鈥渆xcited delirium鈥� as an actual psychological condition. It also points out that EMTs routinely treated subjects suspected of having EXD with , which has the potential to cause respiratory arrest. Because of this, the APA says, 鈥渋t is questionable whether the person identified as having an 鈥榚xcited delirium鈥� actually had any medical condition warranting its use.鈥�
AMA Position Statement on 鈥淓xcited Delirium鈥�
Half a year later, in June 2021, the American Medical Association (AMA) put out its own stating the organization鈥檚 position regarding the term:
A policy adopted by physicians, residents, and medical students at the American Medical Association鈥檚 (AMA) Special Meeting of its House of Delegates (HOD) opposes 鈥渆xcited delirium鈥� 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 鈥渆xcited delirium鈥� 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鈥檚 stance that current evidence does not support 鈥渆xcited delirium鈥� as an official diagnosis, and opposes its use until a clear set of diagnostic criteria has been established
- Denounces 鈥渆xcited delirium鈥� 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 鈥� including ketamine 鈥� 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鈥檚 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 鈥渄e-escalation techniques and the appropriate use of pharmacological intervention for agitated individuals in the out-of-hospital setting.鈥� In the AMA鈥檚 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 on its website, the organization said that 鈥淸a]lthough the terms 鈥楨xcited Delirium鈥� or 鈥楨xcited Delirium Syndrome鈥� 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.鈥�
The next month, the American College of Emergency Physicians (ACEP) on the term 鈥渆xcited delirium鈥� to bring it in line with the APA and the AMA, disavowing the use of the term 鈥渋n clinical settings.鈥� ACEP continues to use the terms 鈥渉yperactive delirium鈥� and 鈥渉yperactive delirium syndrome with severe agitation.鈥�
The American College of Medical Toxicology (ACMT) in May 2023 recommending that its members 鈥渁bandon the term 鈥榚xcited delirium鈥� as a diagnosis and a cause of death.鈥� Notably, the ACMT recognized the continuing need for a term to describe 鈥減atients with altered mental status who are aggressive or have vital signs suggestive of excessive adrenergic activity.鈥� The organization advocated for the term 鈥渉yperactive delirium with agitation,鈥� 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 鈥渆xcited delirium鈥� patients, should be 鈥渕inimized and discontinued as early as possible.鈥�
In October 2023, ACEP withdrew approval of its 2009 white paper, 鈥淩eport on Excited Delirium Syndrome,鈥� recommending that the term 鈥渟hould 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.鈥� This is especially notable because ACEP鈥檚 2009 paper was one of the most-cited sources to justify cases involving the condition. According to an published by the Journal of Emergency Medical Services, the white paper 鈥渟haped police training and still figures in police custody death cases, many involving Black men who died after being restrained by police.鈥�
The same month, the state of California banning the use of 鈥渆xcited delirium鈥� by coroners, medical examiners and law enforcement in any reports. The law, known as , specifies that 鈥渆xcited delirium鈥� is not recognized as a valid medical condition or cause of death in the state and evidence that a person experienced 鈥渆xcited delirium鈥� is inadmissible in any civil action. The law also made a point of banning alternative terms such as 鈥渉yperactive delirium,鈥� 鈥渁gitated delirium鈥� and 鈥渆xhaustive mania.鈥�
Describe, don鈥檛 diagnose
In the wake of the George Floyd case, many states and the District of Columbia enacted and oversight. Quite a few banned the use of chokeholds and neck restraints by law enforcement. Moving away from the use of the term 鈥渆xcited delirium鈥� is an extension of these . 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 鈥渟yndrome鈥� itself. 鈥淓xcited delirium鈥� was never recognized in the medical literature as an actual mental disorder, and anyway, first responders aren鈥檛 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鈥檚 recommended that first responders avoid any medical-sounding jargon and focus on actual observed behavior. In radio traffic, and in public statements, it鈥檚 best to describe the behavior exhibited by the subject. A few examples:
- 鈥淪ubject had stripped to his underwear and was shouting at and attempting to punch anyone who came near him.鈥�
- 鈥淭he subject was aggressive and combative, kicking and spitting and cursing as officers tried to talk to him in order to calm him down.鈥�
- 鈥淭he 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.鈥�
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鈥檚 article, 鈥�.鈥�