Ongoing issues with the diagnosis of excited delirium
Forensic Sci Med Pathol
Ongoing issues with the diagnosis of excited delirium
Roger W. Byard 0 1
0 School of Medical Sciences, The University of Adelaide , Frome Rd, Adelaide, SA 5000 , Australia
1 Roger W. Byard
Excited delirium refers to a clinical situation that is
characterized by a series of typical features that include agitation,
aggression and paranoia, intolerance to pain, unexpected
physical strength, failure to tire despite constant physical activity,
lack of clothing, rapid breathing, profuse sweating, elevated
temperature, an attraction to glass or mirrors, and failure to
respond to police or medical directives [
]. It has had a
controversial history with suggestions being made that it is
simply a “diagnosis” that has been used as a convenient way
of covering up the use of excessive force by police officers .
One of the first descriptions of excited delirium was made
in 1849 by Dr. Luther Bell, a psychiatrist who was working at
the McLean Asylum for the Insane in Massachusetts, United
States. So-called “Bell’s mania manifested as acute exhaustive
mania and delirium that was associated with a 75% fatality
]. The numbers of cases fell after the introduction of
major neuroleptic drugs in the 1950’s but began to rise again
in the 1980’s with the increasing use of cocaine. Other drugs
associated with excited delirium include methamphetamine,
lysergic acid diethylamide (LSD) and phencyclidine (PCP).
New designer drugs, such as the synthetic cathinones and
NBOMe compounds, are also constantly appearing that may
result in acute delirium [
Delirium has been clearly defined in the medical literature
as a transient state where there is disorganization of thought
processes resulting in changes in cognition and consciousness
with disorientation and difficulties separating reality from
]. The “excited” component is added when the
individual exhibits the features listed above. The term was
coined in 1985 by Wetli and Fishbain [
], although it has been
applied differently in different areas of medicine since then
]. The victim is usually an obese male, aged in his thirties,
with a history of either acute-on-chronic drug use or
psychiatric illness such as schizophrenia or mania [
A variety of asphyxial issues may arise during forcible
restraint that range from direct crush asphyxia due to chest
and abdominal compression caused by officers/individuals
lying on top of a struggling individual, to direct neck
compression from bar arm or carotid sleeper holds across the
neck. Careful documentation of the presence or absence of
facial and/or conjunctival petechiae, with layer dissection of
the neck to check for, or to exclude, bruising, are all
important components of the autopsy examination in such cases
]. Abnormal positions of the body, particularly if
hogtied face down with wrists and ankles bound together
behind the back (the so-called prone maximal restraint
position PMRP), may result in lethal positional asphyxia,
although it has been questioned whether this position per se
is sufficient to cause lethal asphyxia without other additive
In cases where there has not been asphyxia the lethal
mechanisms may relate to hyperthermia, drug effect, or
catecholaminergic cardio-respiratory failure from a
“sympathetic storm” with lethal autonomic dysfunction
2, 11, 15
]. Lethal ventricular arrhythmias are not
common, with bradycardic and pulseless electrical activity
being more usual, perhaps exacerbated by acidosis.
The possibility of prolonged QT and Brugada
syndromes should also be considered [
]. Rarely alternative
mechanisms of death such as blunt craniofacial trauma
may be reported [
]. Although the use of Tasers has
been implicated in episodes of fatal excited delirium
no definite causal relationship has been proven [
The levels of drugs detected in decedents have been similar
to those found in recreational drug users, i.e. at levels lower
than those where death has been attributed directly to the drug
itself. Thus, simple drug overdose does not appear to be an
]. Concomitant alcohol use has also been
documented, but this is not always the case. The mortality rate has been
difficult to determine given the lack of pathognomonic
features, however it has been suggested that death only occurs in
a small percentage of cases (most likely <10%) [
A problem with excited delirium is that there is considerable
overlap with the features of other conditions [
]. For example,
the differential diagnosis includes substance abuse or
withdrawal, hypoglycemia, neuroleptic malignant syndrome, heat stroke,
serotonin syndrome, head injury, thyrotoxicosis, seizures,
sepsis, electrolyte abnormalities, and hypoxia [
]. This means
that there is an array of quite diverse conditions to check for at
the time of autopsy. Muscle pallor may be a useful early
macroscopic marker to identify rhabdomyolysis associated with
hyperthermia and cocaine use .
Specialist, non-routine, neuropathological studies in
decedents who have succumbed to excited delirium have shown
alterations in dopamine processing most likely as a result of
unopposed adrenergic stimulation. Dopamine transporters are
reduced and there has been significant elevation in heat shock
protein 70. The exact triggers for these changes remain unclear,
although it may affect primarily hypothalamic centers [
A number of controversies have raged around whether
“excited delirium” can be considered a legitimate medical entity
or not. For example, it has been pointed out that it is not a
diagnosis listed in either the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IVTR) of the American
Psychiatric Association, or in the International Classification
of Diseases (ICD-10) of the World Health Organization [
However, although it is not listed in the ICD9/10, there are a
number of codes that may cover excited delirium including:
delirium (induced by drug or not), agitation (psychomotor),
and abnormal/psychomotor/manic excitement (i.e. codes
292.81Q&R; 293.1 J; 296.00S; 307.9 AD; 780.09E; and
799.2 AM,V&X) [
While it has not been ratified as a diagnosis by medial
organizations such as the American Medical Association or the
American Psychiatric Association (APA), the National
Association of Medical Examiners (NAME) and the American
College of Emergency Physicians (ACEP) both recognize
excited delirium as constituting a medical condition associated
with an increased risk of sudden death [
]. In fact, 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.” .
Despite these endorsements it has not always been
recognized in the courts. For example, in a finding handed down in
the Australian state of Victoria in 2015, where the pathologist
had attributed death to excited delirium, the coroner
concluded that “I find that ‘Excited Delirium’ and ‘Excited
Delirium Syndrome’ are neither appropriate nor helpful for
the ascribing of a medical cause of death” [
So, can excited delirium legitimately be used as a
diagnosis? Certainly it would appear reasonable to use this term in
non-lethal clinical cases and in fatalities with clearly
documented collapse occurring during a typical episode, where
there has been no unusual positioning of the body, or
excessive use of restraining forces, or where there are no underlying
potentially lethal conditions. In situations where there is doubt
concerning the relative contributions of various aspects of the
fatal episode e.g. drug toxicity, restraint, possible positional
asphyxia, underlying significant medical conditions etc., it
may be more useful to list the cause of death as
“undetermined” and to then comment on the possible role, or not, of
each potential predisposing factor.
While there appears to be no doubt that lethal and
nonlethal episodes of excited delirium do occur, there is a lack
of both a consistent definition and a clear understanding of the
precise etiology and pathophysiological pathways [
2, 8, 18
The association of these episodes with aggressive and aberrant
behavior and possible illicit drug taking will often result in the
involvement of law enforcement officers [
dissecting out the story line and potential lethal mechanisms remains
a vital component and an important challenge in each case. It
is also important to avoid becoming bogged down in the mire
of semantic discussions – no matter what terminology is used,
it is apparent that some individuals will collapse and die in an
agitated state during encounters with police for reasons that
are often far from clear.
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