“Excited Delirium”: Dehumanizing and Unscientific
By Kevin Fiscella, MD, MPH, and Debra A. Pinals, MD
Delirium is a serious medical condition characterized by acute disturbance in mental and cognitive function, often including confused thinking, reduced awareness of the environment, behavioral dysregulation, and heightened agitation. “Excited delirium,” on the other hand, is a controversial, unscientific term sometimes used to describe a highly agitated person displaying aggressive behavior and physical strength. We feel the term is dehumanizing, connotes racial stereotypes, may evoke the use of extreme, potentially lethal force, and should not be used in correctional health care.
Because substance intoxication and serious mental illness are common conditions among people who are incarcerated, correctional health professionals often encounter individuals who are experiencing agitation, delirium, or both. However, as we explained in the article “Excited Delirium: Erroneous Concepts, Dehumanizing Language, False Narratives, and Threat to Black Lives” in Academic Emergency Medicine, labeling those people as having excited delirium can impede appropriate care and contribute to avoidable deaths. It is therefore critical for those working in corrections to understand the fundamental distinction between excited delirium and the legitimate diagnosis of delirium.
Delirium is a medically urgent and at times emergent condition involving the brain in the same way that a heart attack is a medical emergency involving the heart. Delirium is most often seen in corrections as a result of acute substance intoxication or acute withdrawal and/or mental illness such as severe acute psychosis. However, life-threatening medical causes, such as metabolic derangement, hypoxia, electrolyte disturbance, and brain injury, should not be overlooked.
Delirium is an established diagnosis recognized by the Diagnostic and Statistical Manual version 5 (DSM-5) and by existing International Classification of Diseases, Tenth Revision (ICD-10) codes. In contrast, excited delirium is not recognized by DSM-5 or by any single ICD-10 code.
About Excited Delirium
The concept of excited delirium, originally endorsed by the American College of Emergency Physicians, has been used in corrections, often by correctional officers, to describe a highly agitated individual displaying aggressive behavior and extreme physical strength.
But excited delirium is a label that is all too often used retrospectively to explain a cause of death, and used prospectively, by both nonmedical and medical personnel, to direct care, sometimes leading to inappropriate use of sedation, restraints, and escalation to arrest and correctional confinement.
In the context of custody, the notion that an individual experiencing excited delirium possesses superhuman strength and imperviousness to pain can evoke extreme use of force rather than minimum restraint needed for the patient’s safety and treatment. Extreme force can be lethal: a synthesis of research published in Forensic Science, Medicine and Pathology concluded that “excited delirium” is typically used when a death occurred in the context of aggressive restraint methods.
Furthermore, excited delirium is disproportionately applied to African-American men. Reports in the literature indicate that independent risk factors for individuals labeled as having excited delirium include being young, African American and male, raising concerns that the diagnosis is tainted by racial bias and lack of clinical diagnostic clarity. A 2018 systematic review by Gonin et al. published in Academic Emergency Medicine showed “low to very low levels of evidence for excited delirium.” A comprehensive report by Physicians for Human Rights concluded that excited delirium that “cannot be disentangled from its racist and unscientific origins.”
Yet excited delirium has become a label, particularly when applied to African American men, that can evoke racist stereotypes that dehumanize the patient. The term can shape interactions that involve force and even possibly excessive dosing of medications.
In 2020, the American Psychiatric Association approved a position statement that stated: “The term excited delirium is too non-specific to meaningfully describe and convey information about a person. ‘Excited delirium’ should not be used until a clear set of diagnostic criteria are validated.” In 2021, the American Medical Association publicly stated that the current evidence does not support excited delirium as an official diagnosis, so “opposes its use until a clear set of diagnostic criteria has been established.” Further, the AMA denounced the term as a sole justification for law enforcement’s use of excessive force. Notably, in 2021, the ACEP tacitly withdrew its support for the term excited delirium and now uses “hyperactive delirium,” defined as a life-threatening constellation of symptoms manifested as a clinical syndrome, adding that the combination of vital sign abnormalities, metabolic derangements, altered mental status/agitation, and potential physical trauma raises serious concerns for impending danger.
In summary, excited delirium is an unvalidated concept that is dehumanizing, and stereotyping. False beliefs associated with the term can impede appropriate response to a medical and/or psychiatric emergency. We feel it is time for the correctional community to abandon the term.
About the authors:
Kevin Fiscella, MD, MPH, is Dean’s Professor of Family Medicine, Public Health Sciences and Community Health at the University of Rochester. He is the American Society of Addiction Medicine liaison to the NCCHC Board of Representatives.
Debra A. Pinals, MD, is a Clinical Professor and MDHHS Medical Director for Behavioral Health and Forensic Programs at the University of Michigan. She is the American Psychiatric Association liaison to the NCCHC Board of Representatives.