For decades, the term “excited delirium” has been misused as a catch-all medical diagnosis for people who have died in police custody, despite having no legitimate scientific roots, according to a new investigative report.
Although delirium and its subtypes are recognized by the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is no clear definition or diagnostic standard for “excited delirium”. Likewise, neither the American Medical Association nor the American Psychiatric Association recognizes the validity of the diagnosis, Harvard neurologist Altaf Saadi, MD, MSc and colleagues reported.
During a virtual roundtable on the report, published together with a commentary on it in The Lancet, Saadi called excited delirium a “practical diagnosis” because the symptoms that are believed to be indicative of the disease are quite varied. Restlessness, confusion, hallucinations, elevated temperature, rapid heart rate and profuse sweating are just a few of its supposed symptoms – all of which may be characteristic of many other medically valid conditions and disorders.
“Law enforcement can use it to describe virtually anyone with a wide variety of underlying conditions, exhibiting a wide variety of symptoms shared by many common conditions, justifying the use of super-aggressive tactics “, said Saadi. “So what [it can be used] hiding behind medical terminology that shifts the blame from the person exerting the force to the person who is dying.”
The report, published by Physicians for Human Rights (PHR), a US-based nonprofit, details the history of the term as being almost always used to describe black and brown Americans who have died in police custody. Thus, they argued, the term “cannot be disentangled from its racist and unscientific origins”.
“Excited delirium” was first coined by pathologist Charles Wetli, MD, with psychiatry professor David Fishbain, MD, in the early 1980s. Saadi’s group wrote that Wetli used the false diagnosis to explain how more than 12 black women – alleged sex workers – have died in Miami after using small amounts of cocaine.
When a 14-year-old girl was murdered under similar circumstances with no cocaine in her system, Wetli’s supervisor concluded that all of the women were murdered. A serial killer was later tried and found guilty of these crimes. But even as alternative causes of death were discovered and proven, Wetli apparently continued to push the “excited delirium” theory, arguing that the combination of sex and cocaine must have contributed to their deaths.
“I have a hard time accepting that you can kill someone without a struggle when they’re on cocaine…cocaine is a stimulant. And those girls were resourceful,” Wetli reportedly said.
“Seventy percent of people who die of coke-induced delirium are black men, even though most users are white. Why? It might be genetic,” he added, according to the PHR report.
The term was given new life in 2007, when Taser International – the company behind the hand-held Taser and stun guns, now called Axon Enterprise – purchased and distributed numerous copies of a book titled excited delirium syndrome, written by Vincent Di Maio, MD, a pathologist who testified on behalf of Taser/Axon. The book, the PHR report says, was distributed at conferences attended by medical examiners and police chiefs.
The diagnosis has been attributed to a number of people of color who have died at the hands of police forces in recent years, including Manuel Ellis, Elijah McClain, Natasha McKenna and Daniel Prude. He also appeared as a defense for Derek Chauvin’s murder trial for the death of George Floyd.
A survey conducted by the Austin American Statesman found that more than one in six of the 289 deaths in Texas police custody from 2005 to 2017 were attributed to “excited delirium”. A report of Florida today showed that of the 85 deaths attributed to “excited delirium” since 2010, 62% involved the use of force by law enforcement.
When University of California, Berkeley law and bioethics professor Osagie Obasogie, JD, PhD, conducted a review of available databases, he found 166 in-custody deaths attributed to “excited delirium” from 2010 to 2020. Of these, 43.3% were black; Blacks and Latinx people together accounted for at least 56% of those deaths.
During the PHR panel, Joye Carter, MD, medical examiner and the first black American woman to be appointed as the chief medical examiner in the United States, explained why she had never used the term in her many years on the job.
“My training was, if you had someone who died…with documented activity such as attraction to shiny objects, elevated body temperature, inability to relate to their physical surroundings, possibly enduring pain , but then you found the cocaine in their system, which was called ‘complications of cocaine use’ or even ‘cocaine psychosis’,” Carter said. “The use of ‘excited delirium’ takes away the ability to carry out a neutral and factual investigation into the death.”
Scholars have recounted the death of Martin Harrison in 2010 as an example of the consequences of the term. Harrison was arrested in Oakland, Calif., for jaywalking; officers discovered an outstanding warrant for failing to appear in court for another offense and took him into custody.
Harrison, who was visibly intoxicated at the time of his arrest, told a nurse on admission that he drank daily and had previously experienced alcohol withdrawal. Although he knows it, he was sent to a cell without any medical treatment. A few days later, he began experiencing symptoms of severe alcohol withdrawal, also known as delirium tremens, which can be treated with medical intervention. According to the report, Harrison’s hallucinations brought 10 deputies to his cell, where they then restrained and beat him to death.
In the ensuing trial against Alameda County, both Di Maio and Wetli were called as expert witnesses. Although neither party disputed that Harrison suffered from delirium tremens at the time of his death or that he had been badly beaten, Wetli still clung to his “excited delirium” theory. In his testimony, Wetli said Harrison’s death was a “classic example of death due to excited delirium.” The case was settled for $8.3 million after an 8-week trial.
The PHR report concluded with a number of recommendations, including the implementation of alternative emergency responses for people in crisis. They also called on the American College of Emergency Physicians to reconsider its position on “excited delirium” and rescind its previous white papers that supported the term as its own diagnosis, separate from other types of delirium.
“There is a growing recognition in the medical community that this is something we need to talk about more,” Saadi said.
All authors have stated that they contributed to the PHR report, “Excited Delirium and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis”. No other conflicts of interest were disclosed.