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Tuesday, July 01, 2003

Excited delirium: Does it exist?

July-September 2003
Mary Paquette, Perspectives in Psychiatric Care

Each year, a small number of people die suddenly while being restrained. Most of these deaths are associated with individuals who were restrained while being taken into custody during a violent police encounter. Other sudden restraint deaths involve people in detention or residential treatment programs who were restrained during violent encounters while also under the influence of psychiatric medications.

There is a great deal of confusion about the cause and circumstances surrounding restraint-related sudden deaths. What is known is that there is a higher rate of sudden death during restraint encounters. Medical authorities typically have had extreme difficulty in identifying the cause of death by autopsy alone.

The "in-custody" death syndrome was first used to describe unexplained deaths when there was no apparent cause other than a police arrest. Research revealed that these individuals exhibited a form of behavioral disturbance that went beyond the distressed state that police normally face (Connor, 2003). The features of this extreme state, referred to as "excited delirium," include agitation, excitability, paranoia, aggression, great strength, and numbness to pain. When confronted or frightened, these delirious individuals can become oppositional, defiant, angry, paranoid, and aggressive.

There are many known causes of an acute behavioral disturbance (e.g., brain tumors, infection, heat exhaustion, thyroid disease, illegal drugs, psychiatric medications), but excited delirium is a largely unknown medical condition. Excited delirium was originally coined by medical researchers to describe the extreme end of a continuum of drug abuse effects such as cocaine-induced excited delirium (Ruttenber, McAnally, & WetH, 1999). Even though the American Medical Association does not recognize this diagnosis as a medical or psychiatric condition, the National Association of Medical Examiners has recognized it for more than a decade (Costello, 2003). It is used by medical examiners in most major cities. Thus, there is a great deal of controversy regarding the use of this syndrome to explain sudden death while restrained.

Opponents of excited delirium theory say they have never seen any proof that someone can be excited to death. The American Civil Liberties Union (ACLU) and the National Association for the Advancement of Colored People fear that the condition is being exploited and used as a medical scapegoat for police abuse (Costello, 2003). They believe most of these people do not die from drugs or some mysterious syndrome but from confrontation, abuse, and inappropriate use of force and restraint during a violent encounter that should have been avoided. They theorize that the cause is due to the psychological stress of being confronted with aggression that results in further physiological reactions (e.g., adrenaline release, increased heart rate, temperature, strength), leading to death. The fact that many of these deaths happen during or soon after restraint clearly implies police abuse. The ACLU believes that most Incustody deaths are the result of excessive force and improper restraint techniques such as hog tying and the use of pepper spray. Many police departments have banned hog tying, which has been blamed for deaths due to positional asphyxia.

Proponents of excited delirium (e.g., medical examiners, police) argue that people who die of the excited delirium death syndrome while restrained are not the victims of incompetence or brutality (Benner & Isaacs, 1996), but rather victims of their own long-term cocaine and amphetamine abuse, which can trigger this fatal syndrome. According to medical examiners, the force of restraining a weakened individual has nothing to do with the death. Some researches believe that the real cause of death is a long-term use of cocaine, which causes heart disease (Ruttenber et al., 1999). Being high on stimulants and being paranoid lead to delirium and a heightened heart rate, often accompanied by a rise in body temperature.

Researchers believe there is a genetic fault that impairs the brain's ability to increase the number of drug receptors in the brain, which helps pump dopamine and other excess hormones out of the brain. Therefore, drug use results in a dangerously high level of hormones in the amygdala, which brings on the delirium and aggression. Antipsychotic medications may have the same effects as stimulants for those susceptible to excited delirium. Since the 1960s, psychiatrists have documented cases of patients who took large amounts of antipsychotic medication, suddenly became manic and aggressive, and later died, usually after being restrained (Costello, 2003).

What is the impact of this issue on advanced practice psychiatric nurses? As a matter of law, any person who chooses to restrain someone may be charged and found responsible regardless of intended or unintended impact, for this reason alone, the decision to use for ce and restraints should be necessary, reasonable, valid, and used only as a last resort. There are justified and unjustified uses of force and restraint, and nurses need to question whether force and restraint are truly necessary and not used prematurely.

Connor (2003) gives several recommendations for healthcare workers to minimize the occurrence of excited delirium and sudden death in the hospital and treatment centers:

1. Carefully screen and monitor people who have recently started a trial of medication, especially medication that has serious side effects and interaction effects.

2. Learn how to recognize the initial symptoms of delirium.

3. Obtain immediate medical consultation, evaluation, and attention for any person who may suffer from delirium.

4. Contain behavior rather than restrain behavior when the patient is not a danger to self or others.

5. Avoid the use offeree if at all possible and, if needed, use the lowest level of force and method of restraint that would not cause aspiration.

6. Use communication tactics that may calm the individual before using tactics that represent confrontation.

7. Educate others (particularly the police) as to the symptoms, causes, and identification of excited delirium.

Amphetamine morbidity has taken on epidemic proportions, which increases drug-related emergencies. This means there will be an increased need for police to handle such incidents, and therefore an increase in sudden in-custody deaths. More research is needed to determine who is most at risk for excited delirium. One of our highest priorities needs to be educating police officers on how to approach individuals who are demonstrating an acute behavioral disturbance that is not criminal in nature, but a psychiatric condition that requires special care.


Benner, A.W., & Isaacs, M. (1996). Excited delirium: A two-fold problem. Retrieved June 1, 2003, from www.zarc.com/english/other/other_sprays /reports /excited_delirium.html.

Connor, M. (2003). Excited delirium, restraint asphyxia, positional asphyxia and "in-custody death" syndromes. Retrieved june 1, 2003, from www.educationoptions.org / programs / articles / SuddenDeath.htm.

Costello, D. (2003, April 21 ). Excited delirium as a cause of death. Los Angeles Times, pp. 1A, 4A.

Ruttenber, A.J., McAnally, H.B., & Wetli, C.V. (1999). Cocaine-associated rhabdomyolsis and excited delirium: Different stages of the same syndrome. American Journal of Forensic Medical Pathology, 2, 120-127.

Mary Paquette, PhD, APRN, BC