Excited delirium

Excited delirium is a controversial proposed condition that manifests as a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behaviour, insensitivity to pain, elevated body temperature, and superhuman strength.[1][2] Excited delirium is sometimes called excited delirium syndrome if it results in sudden death (usually via cardiac or respiratory arrest), an outcome that is sometimes associated with the use of physical control measures, including police restraint.[1][2]

Signs and symptoms

The signs and symptoms for excited delirium may include:[2][3][4][5][6]

Mechanisms

The pathophysiology of excited delirium has been unclear,[4] but likely involves multiple factors.[7] These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal cardiac arrhythmias.[7]

Diagnosis

Other medical conditions that can resemble excited delirium are panic attack, hyperthermia, diabetes, head injury, delirium tremens, and hyperthyroidism.[8]

Epidemiology

Excited delirium is claimed to arise most commonly in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV.[1][9] Alcohol withdrawal or head trauma may also contribute to the condition.[3] A substantial majority of fatal case reports involved men. Excited delirium patients commonly have acute drug intoxication, generally psychostimulants such as cocaine, PCP, MDPV, and methamphetamine.[2] Other drugs that may contribute to death are antipsychotics.[10][11][12]

History

In 1849 a similar condition was described by Luther Bell as "Bell's mania".[13]

It was first described under the name "excited delirium" in 1985 as a condition relating to acute cocaine intoxication.[3][14]

Controversy

Lack of classification in DSM

Excited delirium is not found in the current version of the Diagnostic and Statistical Manual of Mental Disorders. Eric Balaban of the American Civil Liberties Union argued in 2007 that excited delirium was not recognized by the American Medical Association or the American Psychological Association and 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."[15] Melissa Smith of the American Medical Association stated in 2007 that the organization had "no official policy" on the condition.[16]

However the term "excited delirium" has been accepted by the National Association of Medical Examiners and the American College of Emergency Physicians, who argued in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9.[1]

In Australia, excited delirium is not recognised by the Australasian College for Emergency Medicine, the Australian Medical Association or any other registered medical body, nor in law: in 2015, a case of a male who had been ruled to have died from excited delirium was overturned by a ruling in the Victorian Coroners Court, with the presiding coroner finding that excited delirium and excited delirium syndrome are neither appropriate nor helpful for the ascribing of a medical cause of death.[17]

TASER use

Some civil-rights groups argue that excited delirium diagnoses are being used to absolve law enforcement of guilt in cases where alleged excessive force may have contributed to patient deaths.[18][19][20] In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.[20]

In Canada, the 2007 case of Robert Dziekanski received national attention and placed a spotlight on the use of tasers in police actions and the diagnosis of excited delirium. Police psychologist Mike Webster testified at a British Columbia inquiry into taser deaths that police have been "brainwashed" by Taser International to justify "ridiculously inappropriate" use of the electronic weapon. He called excited delirium a "dubious disorder" used by Taser International in its training of police.[21] In a 2008 report entitled An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police, the authors argued that excited delirium should not be included in the operational manual for the Royal Canadian Mounted Police without formal approval after consultation with a mental-health-policy advisory body.[22]

A 2010 systematic review published in the Journal of Forensic and Legal Medicine argued that the symptoms associated with excited delirium likely posed a far greater medical risk than the use of tasers, and that it seems unlikely that taser use significantly exacerbates the symptoms of excited delirium.[23]

In 2015, Natasha McKenna was tasered four times and went into cardiac arrest and died while under police custody. The autopsy report findings said the death was accidental, with excited delirium as a contributing factor due.[24][25][26]

See also

References

  1. 1 2 3 4 ACEP Excited Delirium Task Force (September 10, 2009). "White Paper Report on Excited Delirium Syndrome". American College of Emergency Physicians.
  2. 1 2 3 4 Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR (March 2009). "Excited delirium deaths in custody: past and present". Am J Forensic Med Pathol. 30 (1): 1–5. doi:10.1097/PAF.0b013e31818738a0. PMID 19237843.
  3. 1 2 3 Samuel E, Williams RB, Ferrell RB (2009). "Excited delirium: Consideration of selected medical and psychiatric issues". Neuropsychiatr Dis Treat. 5: 61–6. doi:10.2147/ndt.s2883. PMC 2695211Freely accessible. PMID 19557101.
  4. 1 2 Lisa Hoffman (November 2009). "ACEP Recognizes Excited Delirium as Unique Syndrome". Emergency Medicine News. 31 (11): 4. doi:10.1097/01.EEM.0000340950.69012.8d.
  5. ↑ Alan W. Benner, Excited Delirium, 1996
  6. ↑ "Excited Delirium.org: For Law Enforcement". University of Miami. Retrieved 2011-07-01.
  7. 1 2 Otahbachi M, Cevik C, Bagdure S, Nugent K (June 2010). "Excited delirium, restraints, and unexpected death: a review of pathogenesis". Am J Forensic Med Pathol. 31 (2): 107–12. doi:10.1097/PAF.0b013e3181d76cdd. PMID 20190633.
  8. ↑ "What other medical emergencies can look like excited delirium?". PoliceOne.com. October 2006. Retrieved 2007-03-26.
  9. ↑ Ruth SoRelle (October 2010). "ExDS Protocol Puts Clout in EMS Hands". Emergency Medicine News. 32 (10): 1, 32. doi:10.1097/01.EEM.0000389817.48608.e4.
  10. ↑ "Toxicology and overdose of atypical antipsychotics" J Emerg Med. 2012 Nov;43(5):906-13. doi: 10.1016/j.jemermed.2012.03.002. Epub 2012 May 1.
  11. ↑ "Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management." CNS Drugs. 2012 Jul 1;26(7):601-11. doi: 10.2165/11631640-000000000-00000.
  12. ↑ "Ventricular arrhythmias and cerebrovascular events in the elderly using conventional and atypical antipsychotic medications." J Clin Psychopharmacol. 2007 Dec;27(6):707-10.
  13. ↑ Kraines. "Bell's Mania". The American Journal of Psychiatry.
  14. ↑ Wetli CV, Fishbain DA (July 1985). "Cocaine-induced psychosis and sudden death in recreational cocaine users". J. Forensic Sci. 30 (3): 873–80. PMID 4031813.
  15. ↑ "Death by Excited Delirium: Diagnosis or Coverup?". NPR. Retrieved 2007-02-26. You may not have heard of it, but police departments and medical examiners are using a new term to explain why some people suddenly die in police custody. It's a controversial diagnosis called excited delirium. But the question for many civil liberties groups is, does it really exist?
  16. ↑ "Excited Delirium: Police Brutality vs. Sheer Insanity". ABC News. March 2, 2007. Retrieved 2007-03-13. Police and defense attorneys are squaring off over a medical condition so rare and controversial it can't be found in any medical dictionary — excited delirium. Victims share a host of symptoms and similarities. They tend to be overweight males, high on drugs, and display extremely erratic and violent behavior. But victims also share something else in common. The disorder seems to manifest itself when people are under stress, particularly when in police custody, and is often diagnosed only after the victims die.
  17. ↑ "Finding into Death with Inquest – Inquest into the Death of Odisseas Vekiaris" (PDF). Coroner's Court of Victoria at Melbourne. December 18, 2015.
  18. ↑ Truscott A (March 2008). "A knee in the neck of excited delirium". CMAJ. 178 (6): 669–70. doi:10.1503/cmaj.080210. PMC 2263095Freely accessible. PMID 18332375.
  19. ↑ Paquette M (2003). Paquette, Mary, ed. "Excited delirium: does it exist?". Perspect Psychiatr Care. 39 (3): 93–4. doi:10.1111/j.1744-6163.2003.00093.x. PMID 14606228.
  20. 1 2 "'Excited delirium' as a cause of death", Daniel Costello, Los Angeles Times, April 21, 2003
  21. ↑ Hall, Neil (2008-05-14). "Police are 'brainwashed' by Taser maker; Psychologist blames instructions". Vancouver Sun. Canwest. pp. A1. Retrieved 2008-08-30.
  22. ↑ "An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police", John Kiedrowski, Royal Canadian Mounted Police, June 5, 2008
  23. ↑ Jauchem JR (January 2010). "Deaths in custody: are some due to electronic control devices (including TASER devices) or excited delirium?". J Forensic Leg Med. 17 (1): 1–7. doi:10.1016/j.jflm.2008.05.011. PMID 20083043.
  24. ↑ Weil, Martin (28 April 2015). "Death of woman shocked by stun gun in Fairfax jail is ruled an accident". The Washington Post. Retrieved 30 October 2015.
  25. ↑ "Inmate: McKenna, Natasha 1054527; Incident Date: 01/27/2015" (PDF). County of Fairfax, Virginia. Retrieved 30 October 2015.
  26. ↑ Morrogh, Raymond F. (8 September 2015). "Report of Investigation In-Custody Death. Date of Incident: 2/3/2015; Location: Fairfax County Adult Detention Center; Descendent: Natasha J.C. McKenna" (PDF). Office of the Commonwealth's Attorney. Retrieved 30 October 2015.

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