Emergency medical association rejects ‘excited delirium,’ used to describe some deaths in police custody

By Jen Christensen, CNN

(CNN) — An emergency physicians group is disavowing “excited delirium,” a controversial term that some police officers, clinicians, medical examiners and court experts have used to explain how an agitated person could die in custody through no fault of any force used to subdue them.

Dr. Michele Heisler, medical director for Physicians for Human Rights, says that the American College of Emergency Physicians’ (ACEP) move will take excited delirium off the table in court cases. “This is the final professional medical or psychological or psychiatric association to repudiate the term,” she said.

Excited delirium has been described by other medical associations as “associated with racism” and disproportionately used in the deaths of Black people. It was cited in one of the most high-profile cases of recent years: the death of George Floyd in 2020.

ACEP’s Board of Directors confirmed Thursday that its 2009 white paper on excited delirium syndrome is “outdated and does not align with the College’s position based on the most recent science,” according to a statement on the organization’s website.

“The term excited delirium should 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,” the statement says.

This decision officially withdraws the board’s approval of the paper.

Joanna Naples-Mitchell, US research adviser to Physicians for Human Rights and co-author of a 2022 report that traced the history and impact of this term and showed how excited delirium was often cited in deaths in police custody, said ACEP’s move was “a tremendous turning point.”

The white paper has been “extremely influential,” she said, and one of the main reasons the term could be used in court.

“Part of the reason that paper is so harmful is because not only has it been cited in court, but the content of the paper puts forth this definition of signs and symptoms of excited delirium that includes terms that have racist undertones and in fact may encourage law enforcement to use excessive force, including saying that someone with a delirium may have superhuman strength and [be] impervious to pain, and may not actually be able to respond to typical uses of force that are nonlethal,” she said.

The paper was often used to bolster evidence in court, including in expert testimony in the trial of Derek Chauvin for the murder of Floyd. Experts would sometimes cite it to argue that the death of someone in custody lay with the person themselves rather than the actions taken by police.

ACEP considered the syndrome a subcategory of delirium. Someone with excited delirium has been described in studies as being agitated, aggressive or disoriented, and the thinking was that this heightened state of emotion could lead to their death.

Technically, excited delirium was never considered an official diagnosis because it isn’t listed in the reference materials used by mental health professionals or in the codes that health care facilities use to chart a diagnosis for insurance purposes and research. There is no blood or diagnostic test that can detect it. The 2022 Physicians for Human Rights report concluded that the term was “scientifically meaningless.”

There is no national database tracking cases of “excited delirium,” but in one study, data showed that from 2010 to 2020, “there were 166 reported instances where a person died in police custody and excited delirium was described as a possible cause of death.” Black people made up 43% of those deaths, despite composing only 13% of the US population, according to the US Census.

The term drew additional attention after the 2019 death of Elijah McClain, a Black massage therapist who died after being put in a carotid hold by police. Paramedics had also injected him with ketamine. One of the officers involved in the incident was found guilty of criminally negligent homicide and assault by a jury on Thursday, while another was acquitted of all charges. Two paramedics are also scheduled to go on trial in the coming weeks, and they have pleaded not guilty.

In Floyd’s case, the Minneapolis police officer who held down his ankles was overheard saying “I just worry about excited delirium or whatever.” In court, a police surgeon testified that Floyd did not meet the criteria.

In 2020, the American Psychiatric Association adopted a position against the diagnosis, saying that it was “nonspecific” and “lacks clear diagnostic criteria” and that it should not be used until such criteria are validated. The organization also called for the development of evidence-based protocols for when first responders use ketamine in emergency situations.

“It is of concern that it can be used often retrospectively as a way to explain use of force in law enforcement contexts,” Dr. Debra Pinals, chair of the APA Council on Psychiatry and Law, told the association’s Psychiatric News at the time of McClain’s death.

Also in 2020, the American Medical Association adopted a policy that opposed excited delirium as a medical diagnosis. The group warned first responders against using pharmacological interventions without a legitimate medical reason.

The American Medical Association said its policy came about because of a pattern of police using the term and pharmacological interventions like ketamine as a “justification for excessive police force, disproportionately cited in cases where Black men die in law enforcement custody.”

In February, the American College of Medical Toxicology said that because it is used in “multiple distinct contexts with various underlying causes, and has become associated with racism, it is time to discontinue the use of this term.”

In April, the National Association of Medical Examiners issued a statement that asked its members to stop listing excited delirium as a cause of death.

This week, California Gov. Gavin Newsom signed legislation that would make the state the first to ban excited delirium as a diagnosis and as a cause of death.

ACEP has been considering the issue for years. In 2021, a task force decided that the organization should not recognize the use of “excited delirium” and argued that it should no longer be used in clinical settings. Disavowing the paper, as the group did this week, makes the statement stronger, and experts say this means it should no longer be used in court.

The group does, however, recognize a similar term, “hyperactive delirium with severe agitation,” which it says is a “potentially life-threatening clinical condition characterized by a combination of vital sign abnormalities, pronounced agitation, altered mental status, and metabolic derangements.”

When dealing with someone with hyperactive delirium, the organization advised in April, first responders should focus on reducing stress, preventing physical harm and taking the person to a hospital where they can be treated by an emergency physician.

Heisler, who is also a professor of internal medical and public health at the University of Michigan, says excited delirium “is just a baseless concept and should never have been used as a diagnosis – and certainly not as a cause of death.”

Heisler says she hopes ACEP will now work to educate its membership about the policy change to ensure that the concept is never used again.

CNN’s Julia Jones, Amir Vera, Carma Hassan, Amanda Musa and Markian Hawryluk contributed to this report.

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