Are people in police custody dying of excited delirium?

February 28, 2007

Imagine a person in the middle of the street, yelling nonsense and stumbling about, unable to keep his balance, obviously not in his right mind. He is waving a knife at bystanders and at the police who have been called to the scene. The police try to convince the man to put the knife down, but he clearly has no idea they're even talking to him. So the police take action: They draw their guns and move toward him. The man responds violently, hysterically, jabbing the knife at police. With six officers working together, they're finally able to restrain him and get him on the ground, but he's still thrashing around with what seems like superhuman strength. They start hitting him with their night sticks, and they keep hitting him until he calms down. But then they realize he's not just calm. He's dead.

In this theoretical incident, if the medical examiner can rule out the police beating as the cause of death and can find no clear indication of a fatal, biological occurrence, he or she may determine that the official cause is excited delirium. If ever there were a controversial diagnosis, "excited delirium" is it. It's not recognized by the American Medical Association as a medical condition, and you won't find it in the American Psychiatric Association's handbook of mental disorders, but it's the official cause in hundreds of "in-custody deaths" every year. While the majority of these deaths happen in police custody, there are a few each year that occur in residential psychiatric treatment programs, as well.

The condition has shown up in medical literature as far back as the 1960s -- some people who overdosed on antipsychotic drugs became violent and paranoid and then suddenly died after being restrained. "Excited delirium" first started appearing on death certificates in the 1980s, often attributed to the effects of long-term cocaine use. Believers in the syndrome typically attribute it to the extended use and or misuse of psychiatric or illicit drugs, and some researchers believe there may be a genetic defect in the brain that causes certain drugs to trigger this type of reaction. The controversy surrounding "excited delirium" is related to two primary issues: First, there are no signs of excited delirium that show up on an autopsy -- it's basically the crib death of the police-custody world; and second, the vast majority of people who die from excited delirium do so after they're beaten by police.

Most police officers will tell you that the type of hectic, crazy situation described above does occur, and that it's very difficult to manage. It can take eight officers to restrain a person in this condition. Most psychiatrists explain that the theoretical knife-wielding lunatic is probably in an altered mental state and is exhibiting "acute behavioral disturbance." This can be brought on by a wide array of factors, including illicit drug use (specifically cocaine and methamphetamine), a brain tumor, heat stroke, or an bad reaction to legal psychiatric drugs, especially stimulants and antipsychotics.

Dr. Mary Paquette, in the journal Perspectives in Psychiatric Care, describes the condition known as "excited delirium" as an extreme state of behavioral disturbance characterized by "agitation, excitability, paranoia, aggression, great strength, and numbness to pain." (Think Tony Montana by the end of "Scarface.") Regardless of what causes the episode -- drug abuse, psychiatric drug interactions or something like head trauma, the person is most likely suffering from symptoms like increased body temperature and heart rate and a disoriented mental state -- he or she may have no real awareness of reality and may even be hallucinating. Medical professionals theorize that when someone in this state ends up surrounded and then rushed by police officers, things get markedly worse. The person may become terrified, increasingly violent, furious and confrontational.

These types of acute behavioral disturbances are well-documented in the psychiatric literature. Where things get uncertain is when this condition leads to sudden death, because increased body temperature and a rapid heart rate are not necessarily fatal. In the case we've described, if the medical examiner was able to rule out beating as the cause of death, then what happened?

No one really knows. Excited delirium is not a phenomenon that scientists can study in a controlled environment. There are those who say the man died from excited delirium, and there are those who say there is no such thing. The latter group believes the man died from bad police tactics.

Proponents of excited delirium explain that the person's altered mental state and the corresponding biological symptoms are the cause of death. Depending on which expert you ask, the person essentially dies of an adrenaline overdose, heart failure and/or a rapid increase in body temperature that leads to complete organ failure, usually resulting from acute, long-term drug abuse. Those who say excited delirium is real are divided on the role of the police officers in the death: Either the police actions have nothing to do with the death -- the person would have died whether or not the police had intervened; or it is the subject's resistance to restraint, not the police's restraint methods themselves, that cause a fatal reaction.

Skeptics claim the reality is actually the reverse. It is the police actions that are the cause of death, and the person's mental state is either caused or exacerbated by the use of improper restraint methods and excessive force. At its most extreme, the skeptical position says "excited delirium" is a nonexistent condition that police have invented to cover up instances of excessive force that turn deadly.

Which brings us to another, related problem with the excited delirium diagnosis: It's often associated with the use of stun guns. And in recent years, Taser International, the maker of most police-issued stun guns, has used the defense of "excited delirium" in numerous lawsuits. People are suing the company for deaths they say are directly caused by the use of stun guns in the police restraint process. The fact that the company's consistent defense is "excited delirium" doesn't help build legitimacy for the diagnosis, considering how much money is at stake in those lawsuits.

Proof of legitimacy aside, many experts in the psychiatric field place "death by excited delirium" under the umbrella of "restraint-related deaths," and that understanding of the syndrome would seem to imply that police actions do play some role in the fatal outcome. Dr. Michael G. Conner, in "Excited Delirium, Restraint Asphyxia, Positional Asphyxia and 'In-Custody Death' Syndromes," notes that "exhaustion, exertion and restraint combined are associated with a high rate of sudden death." And there are emergency room doctors who have treated people with acute behavioral disturbance who say that sedatives can calm them down, and that they're still alive when the episode is over.

But even if the police restraining process is the fatal addition to the equation, there are those who ask what might happen if police do not forcefully restrain a man who is disoriented, aggressive and waving a knife around in the middle of the street. In the end, whether police actions are justified or not is always open for debate. But in the face of terrible press and lawsuits, police departments around the country are instituting training procedures to educate officers on the signs of acute behavioral disturbance and methods of handling it without attempting restraint. Such methods include avoiding direct confrontation, using the person's name and speaking in a calm tone of voice, and setting up "containment" barriers to restrict the person's movement instead of restraining the person by force. The idea seems to be that if the restraint process can be eliminated or at least altered, deaths from "excited delirium" involving police action will start to decline.

For more information on excited delirium and related topics, check out the following links:

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